Browsing by Author "Cunnama, Lucy"

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    A comparative cost analysis of the pathway to diagnosing lymphoma in a tertiary hospital, Western Cape, South Africa
    (2022) Fareed-Brey, Waarisa; Cunnama, Lucy; Verburgh, Estelle; Antel, Katherine
    Cancer is one of the leading causes of death before the age of 70 in 91 countries (out of 172) with a noted increasing incidence of cancer and mortality (Bray et al., 2018). In tuberculosis (TB) endemic areas, a fine needle aspirate (FNA) is often used as the diagnostic tool of choice when trying to understand the underlying cause of lymphadenopathy (LAP), which can lead to delayed diagnosis of lymphoma (Antel et al., 2019). A significant gap exists in the lack of costing of the diagnostic pathway to diagnosing lymphoma. The study aimed to cost the diagnostic pathways, namely FNA, core-needle biopsy (CNB), and surgical excision biopsy (SEB) using secondary data collected in 2018 (February until October) at Groote Schuur Hospital (GSH), within the tertiary level hospital outpatient clinics to informed the patient pathways. The overall purpose of the study was to inform policy-making decisions and process guidelines. A cost analysis study was conducted using a combination of ingredients-based costing and top-down costing from a provider's perspective. Annual costs were calculated and inflated to 2021 South African Rands using the consumer price index (CPI) and converted to United States American Dollars. More CNBs are currently being performed than SEBs at GSH, and when pathways were followed, CNB initiated pathways (US $567) were less costly compared to FNA initiated pathways (US$ 877). The cost of the CNB procedure varied with the use of a single-use biopsy gun and the multi-use Magnum BARD gun. CNB provides an alternate choice to SEB and based on the study conducted, CNB pathways are less costly. The main cost driver for all three procedures was personnel and this could be decreased by task shifting and training of medical officers and interns.
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    A critical assessment of the Rwandan health financing system: implications for health service utilisation
    (2025) Hakuzimana, Alex; Ataguba, John Ele-Ojo; Obse, Amarech; Cunnama, Lucy
    Like many other countries, Rwanda has embraced major health financing reforms to achieve universal health coverage goals and improve access to quality health services without undue financial hardship for its citizens. The public health sector provides most health services in the country, and fragmentation is a major challenge to its health financing system. Literature suggests that fragmentation of health financing may negatively impact the health system's equity, efficiency, and sustainability. Considering the currently available literature, this thesis critically assessed Rwanda's health financing system in relation to the equitable use of health care services, one of the goals of universal health coverage. Various methodological approaches to address different objectives are explored. A case study qualitative approach combining document review and in-depth interviews of key informants indicates that the Rwandan health financing system is fragmented. Using the data from the 2005/2006 and 2010/2011 Integrated Household Living Conditions Surveys, this research shows that despite this fragmentation and contrary to findings from other studies, there was no inequality in public health services use during the two separate periods. These results provide further opportunities for more health sector reforms to improve access to affordable public health services in Rwanda. They also support recommendations to conduct similar analyses to compare these findings with the most recent data to capture the current reality on the equitable use of health care services in public health facilities.
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    A mother’s choice: a qualitative study of mothers’ health seeking behaviour for their children with acute diarrhoea
    (BioMed Central, 2016-11-21) Cunnama, Lucy; Honda, Ayako
    Background: Diarrhoea presents a considerable health risk to young children and is one of the leading causes of infant mortality. Although proven cost-effective interventions exist, South Africa is yet to reach the Sustainable Development Goals set for the elimination of preventable under-five mortality and water-borne diseases. The rural study area in the Eastern Cape of South Africa continues to have a parallel health system comprising traditional and modern healthcare services. It is in this setting that this study aimed to qualitatively examine the beliefs surrounding and perceived quality of healthcare accessed for children’s acute diarrhoea. Methods: Purposive sampling was used to select participants for nine focus-group-discussions with mothers of children less than 5 years old and 11 key-informant-interviews with community members and traditional and modern practitioners. The focus-group-discussions and interviews were held to explore the reasons why mothers seek certain types of healthcare for children with diarrhoea. Data was analysed using manual thematic coding methods. Results: It was found that seeking healthcare from traditional practitioners is deeply ingrained in the culture of the society. People’s beliefs about the causative agents of diarrhoea are at the heart of seeking care from traditional practitioners, often in order to treat supposed supernatural causes. A combination of care-types is acceptable to the community, but not necessarily to modern practitioners, who are concerned about the inclusion of unknown ingredients and harmful substances in some traditional medicines, which could be toxic to children. These factors highlight the complexity of regulating traditional medicine. Conclusion: South African traditional practitioners can be seen as a valuable human resource, especially as they are culturally accepted in their communities. However due to the variability of practices amongst traditional practitioners and some reluctance on the part of modern practitioners regulation and integration may prove complex.
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    A Sensitivity Analysis Framework for Health Economic Evaluation in Middle Income Countries: Appropriately Incorporating a Comprehensive Approach
    (2021) Soboil, Joshua; Cunnama, Lucy; Wilkinson, Tommy
    When constructing a health economic decision model, it is critical to select a sensitivity analysis approach appropriate for the decision context. This point is particularly salient to Middle-Income Countries (MICs), where there is relatively heightened resource scarcity and increased opportunity-cost. MICs face acute shortages of accessible as well as highquality evidence, resulting in a frequent imputing of data from external jurisdictions. Conversely, there are also shortages in skills and research capacity, creating a strong complementary need to consider the contextual feasibility of applying more resource demanding sensitivity analysis methodologies. Given the above, it is therefore critical to establish whether and when the technical benefits of complex and resource demanding methods result in real-world value. We apply a comparative case study using a comprehensive approach to decision-modelling, implemented in the R and JAGS languages. Specifically, the case study replicates a deterministic model originally used to inform the cost-effectiveness of adding a bivalent Human Papilloma Virus (HPV) vaccine to South Africa's public health care cervical cancer screening programme. Crucially, the case study provides critical insight into the pros and cons of implementing more complex sensitivity analysis techniques within MIC climates. Our findings indicate that the benefits of more advanced sensitivity analysis methods are nuanced; are therefore contextually beneficial according to a case-by-case basis; and, moreover, choosing a sensitivity analysis method should be guided by a conceptual ‘fruitfulness' (i.e. a bang-for-buck), more than a mere desire to reduce model complexity. To aid analysts in this process, from our comparative case study we provide a framework with three core concept areas namely Decision-Maker Preferences (Decision Power, Investment, Risk Aversion), Analytical Considerations (Available resources, Indirect Evidence) and Policy Context (Knowledge of Topic, Technical Expertise). The framework intends to encourage more judicious selection of sensitivity analysis methods; help reduce the methodological variation apparent in MIC settings; and simultaneously provide decision-makers with greater methodological transparency in the selection of sensitivity analysis methods.
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    Analysing the socio-demographic determinants of comprehensive HIV/AIDS knowledge among school-going children in Botwana: a multi-level analysis
    (2024) Kgosi, Shatho; Cunnama, Lucy; Ataguba John
    Background: Despite international efforts to contain transmission, the spread of HIV/AIDS remains a problem in some communities. Botswana is one of the countries in sub-Saharan Africa that is most affected by the pandemic and, similar to other countries, Botswana has a higher proportion of HIVinfected young people in comparison to other age groups. Various factors such as wealth disparity, treatment systems, gross domestic product per capita, corruption, religion, education, contraceptive use, and availability of antiretroviral drugs, have been identified as drivers of new HIV infections. Additionally, lack of comprehensive knowledge regarding HIV/AIDS has been cited as a factor in HIV/AIDS transmission. Therefore, tailored HIV prevention and educational interventions are advocated for reasons of efficiency and sustainability. To address knowledge gaps and promote positive and safe sexual behaviour, emphasis has also been placed on behaviour change programs, highlighting the importance of understanding key populations. Objectives: This study sought to investigate the level of comprehensive HIV/AIDS knowledge among school-age children in Botswana as well as the determinants of this cohort's comprehensive knowledge of HIV/AIDS. Methods Setting The data used in this analysis is from a survey that was conducted in 135 private and public schools in Botswana in the ten districts overseen by the Ministry of Basic Education. Data was collected between February and April 2015 (Ministry of Basic Education, 2016). Study Design The data used in this study is from the 2015 Botswana Youth Risk Behavioural and Biological Surveillance Survey (BYRBBSS-II). Stratified multistage sampling was used to select schools and classrooms for participation in the study (Ministry of Basic Education, 2016). The school was the primary sampling unit (first stage), while the classroom was the secondary sampling unit (second stage) (Ministry of Basic Education, 2016). First, the student population was stratified by school district, while schools were selected based on their enrolment size and a list of classes of each sampled school was organised by grade level (grade 8,9,10,11 and 12) (Ministry of Basic Education, 2016). Schools were selected using a sampling frame derived from the 2014 master list of school enrolment data provided by the Ministry of Basic Education (MBE) (Ministry of Basic Education, 2016). Study Population Students were eligible to participate in the study if they regularly attended secondary school, were in grade 8 to 12, had permission from their parents or legal guardians to participate, and gave informed consent and assent (Ministry of Basic Education, 2016). Of a total of 9,590 students eligible to be included in the study, 7,564 (78.9%) provided informed consent or assent and agreed to participate in the survey (Ministry of Basic Education, 2016). The ages of survey participants ranged from 13 to 19 years for both males and females (Ministry of Basic Education, 2016) Inclusion Criteria Students who provide informed consent and assent were included in the study. Exclusion Criteria Those who did not provide informed consent or assent were not included in the study (Ministry of Basic Education, 2016). Schools where there were fewer than 20 students surveyed were also excluded. Data Analysis A multilevel mixed-effects logistic regression was used to identify predictors of comprehensive HIV/AIDS knowledge at individual, school, and regional levels. Results: The overall prevalence of comprehensive HIV/AIDS knowledge was estimated at 58.6%, 95% CI: (57.4% - 59.7%). Female students had higher levels of HIV/AIDS knowledge than their male counterparts. Comprehensive HIV/AIDS knowledge was also positively associated with school grade level completion. Surprisingly, it was found that 13-14-year-olds had higher odds of comprehensive knowledge compared to 15-19-year-olds. In contrast, students in grades 9 to 12 had a higher likelihood of comprehensive knowledge than those in grade 8. The odds of possessing comprehensive knowledge about HIV/AIDS were higher among private school students than among those attending public schools, while students identifying as Christian, demonstrated higher odds than those identifying as belonging to other religions or non-religious. Students who experienced hunger (as a proxy of socioeconomic status) were typically less informed than those who did not experience hunger, and those who resided with their parents during school holidays were more likely to be well-informed compared to those who did not reside with their parents. Conclusion: This study highlights that comprehensive knowledge of HIV/AIDS among students is still quite limited. It also highlights the role of school type, age, grade, and religion as key determinants of comprehensive knowledge of HIV/AIDS. Therefore, any meaningful policy to improve adolescents' knowledge of HIV/AIDS should consider the gaps associated with these determinants. The developed guidelines should aim to disseminate the latest and most relevant HIV/AIDS promotional messages in both private and public schools. In addition, while not neglecting Christians, extra efforts should be made to disseminate HIV/AIDS messages to young people who are non-Christian. What this study adds: this study highlights the importance of comprehensive HIV/AIDS knowledge as an avenue for fighting the pandemic over and above biomedical interventions. Thus, the results of this study should guide programme development on topics that influence young people's understanding of HIV/AIDS to change behaviour. In addition, compared to the previous studies conducted on this topic, by using a multi-level analysis, this study was able to account for intra-cluster correlations in ascertaining the determinants of comprehensive HIV/AIDS knowledge, an innovation that was hitherto lacking in the literature on Botswana.
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    Estimating the treatment cost of colon cancer at Groote Schuur Hospital
    (2025) Nnene, Kelechi; Cunnama, Lucy; Moodley, Jennifer; Ataguba, John
    Background: Due to the high mortality-to-incidence ratio of colon cancer in South Africa, urgent public health measures are needed to improve treatment outcomes. Costing studies can be leveraged to understand the treatment cost burden for colon cancer, providing crucial insights for allocating resources to finance such measures. This study aims to assess treatment options and costs for colon cancer treatment from the perspective of healthcare providers at a public healthcare facility in South Africa. Method: The study used an ingredient-based approach to assess colon cancer treatment costs by stage at the colorectal clinic and combined colorectal oncology unit at Groote Schuur Hospital. The costing process involved two steps: first, treatment options were defined according to facility guidelines and verified through expert interviews; then, these options were linked to relevant cost items for each cancer stage based on expert input. Second, a bottom-up costing method was used to estimate and aggregate per-patient costs across treatment components for each stage. One-way sensitivity analysis addressed uncertainties in post-surgical inpatient admissions and staff categories. All costs are presented in 2024 South African Rands (ZAR) and United States Dollars (USD). Results: Colon cancer treatment components include staging and risk assessment investigations, clinical consultations, surgery and chemotherapy. The estimated guideline-based per-patient costs for treatment are R60,156 ($3,216) for stages I and II (low-risk); R75,132 ($4,017) for high-risk stage II and stage III; and R171,935 ($9,193) for stage IV. Surgical treatment represents a major cost driver, with additional expenses from inpatient admissions following surgery. Sensitivity analysis indicates that reducing postoperative inpatient stay by 25% lowers the treatment cost by approximately 5% across all stages. Conclusion: Colon cancer treatment costs are significant, increasing with each colon cancer stage. To manage these escalating costs and reduce the overall healthcare burden, policies should prioritise early detection and invest in accessible, stage-appropriate interventions to improve patient outcomes.
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    Relationship between Ideal clinic status determination and measures of PHC performance, utilisation and expenditure per PHC facility headcount
    (2025) Van Rensburg, Caitlin; Cunnama, Lucy
    A well-functioning, high-quality primary health care (PHC) system will be essential to achieve the ambitious goals set forth in South Africa's proposed system of National Health Insurance (NHI). NHI, informed by principles of Universal Health Coverage, will introduce a centralised health financing scheme in a bid to improve equity in the current two-tiered (public/private) system of health care delivery. NHI will rely heavily on PHC facilities as the ‘gateway' to the health system. Against this backdrop and the findings of a 2012 facilities audit report which revealed less than 50% of South Africa's public health facilities at the time complied with vital measures for health care delivery, the Ideal Clinic Realisation and Maintenance Programme (ICRMP) was developed as a tool for quality improvement. The ICRMP encompasses a comprehensive framework of standards which primary care facilities should meet, with manuals and training provided for facility staff alongside district support to assist facilities in doing so. Under the ICRMP, clinics are routinely assessed and afforded the status of an ‘Ideal Clinic' if specified minimum scores are met. These assessments should be accompanied by measures to improve areas of the framework under which clinics scored poorly. Facility managers should be supported by a Perfect Permanent Team for Ideal Clinic Realisation and Maintenance (PPTICRM) established at district level to conduct peer reviews and to improve on clinic weaknesses. National implementation of the ICRMP began in 2015/16, although the Western Cape joined only in 2016/17. While assessment/accreditation frameworks are increasingly being utilised globally as tools for quality improvement (as the ICRMP purports to be), evidence in support of their efficacy in achieving their stated goals remains sparse. Literature on the ICRMP is equally limited. Empirical studies considering the impact of early implementation of the ICRMP on indicators of primary care quality have yielded mixed results, suggesting minimal meaningful impact of the programme on patient waiting times, patient perceptions of quality of care, or on other proxy indicators of quality. The objective of the present study is to build on this body of literature assessing the association of the ICRMP with access and quality of care across South Africa over time. Leveraging longitudinal data now available, the effects of the programme on two measures of utilisation and six further indicators of primary care quality spanning maternal and early childhood care, TB/HIV treatment, and non-communicable disease screening are explored using panel regression models. Controlling for heterogeneity across clinics and for year, increases in ICRMP percentage scores over time appear to be associated with very small magnitude increases in childhood PHC utilisation and early usage of antenatal care. Findings, however, reveal no further significant effects on a general PHC utilisation marker nor on other proxy measures of quality included in analysis. While ICRMP percentage scores have improved over time, it appears limited impact of this improvement is evidenced in access and quality of care. Based on these findings, further research into underlying ICRMP element associations with indicators of quality of care is recommended. This may inform a revision of the ICRMP framework to better align scoring with access and PHC quality of care. To avoid the ICRMP becoming merely a tick-box exercise, targeted quality improvement plans as envisaged by the ICRMP and informed by such revised framework should be given renewed focus.
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    Social determinants of comorbid depression among patients living with diabetes and/or HIV at primary healthcare settings in Western Cape Province of South Africa
    (2025) Tintinger, Susanet; Obse, Amarech; Cunnama, Lucy
    The co-occurrence of physical and mental health conditions poses a significant public health challenge globally especially in low- and middle-income countries (LMICs). In South Africa, diabetes, HIV, and depression frequently co-occur in an intricate manner, and the illness experience is largely shaped by the differences between individuals, communities, and provinces. Previous research highlights the influence of socioeconomic factors on the relationship between diabetes, HIV, and depression, although the focus has mainly been on the variability in health outcomes explained by individual-level factors. There is a need for evidence on the mental health outcome variations attributable to distinct contextual levels amongst patients living with HIV and/or diabetes. This dissertation assesses the socioeconomic determinants of depressive symptoms among patients living with HIV and/or diabetes accessing healthcare at the primary health care (PHC) level in the Western Cape province. Furthermore, it examines the variation in depressive symptoms attributable to individual, household, and community levels among this sub-population. Baseline data collected from participants in a cluster randomised controlled trial, named Project MIND conducted in the Western Cape, was used in this analysis. This study applied a three-level multi-level logistic regression analysis. Random intercepts were added at the household and community levels using grouping variables for household socioeconomic status and PHC catchment areas to account for the heterogeneity across the data hierarchy levels. Four random intercept multi-level models were fitted sequentially. The estimated intraclass correlation coefficients (ICCs) were used to determine the proportion of the outcome variance attributable to the grouping- and individual-level variables for each model. Overall, the findings indicate that the variance in depressive symptoms among patients with HIV and/or diabetes can be explained by differences at the household- and community-levels when controlling for individual-level factors. Higher odds of moderate to severe depressive symptoms were significantly associated with being female, secondary level education, and food insecurity. Lower odds of moderate to severe depressive symptoms were associated with harmful/hazardous alcohol use, increased social support, and increased self-efficacy. This study highlights the importance of policies that simultaneously consider individual, household- and community-levels to address co-occurring mental and physical health conditions in the Western Cape. The findings support interventions at the PHC level and in the community to bolster social support systems and self-efficacy, promote mental health from early educational years, prioritise gender-sensitive health programs, and address household food insecurity among patients living with HIV and/or diabetes with depressive symptoms.
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    Systematic review of economic evaluations for paediatric pulmonary diseases
    (2021) Chitando, Mutsawashe; Cunnama, Lucy
    Background Pulmonary diseases are the leading causes of mortality globally amongst children under five years of age. Economic evaluations (EEs) guide decision-makers on which health care intervention to adopt to reduce paediatric pulmonary disease burden. Methods We systematically reviewed EEs for paediatric pulmonary diseases published globally between 2010 and 2020. We searched PubMed, Web of Science, MEDLINE, Paediatric Economic Database Evaluation (PEDE), and the Cochrane library. EEs included were specific to paediatric pulmonary diseases in a hospital setting and of children aged from zero to six years old. We extracted data items guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. We collected qualitative and quantitative data which we analysed in Microsoft Excel and R Software. Results 22 studies met the inclusion criteria. Seven of the articles were cost-effectiveness analyses, five cost-utility analyses, two cost-minimisation analyses, and eight cost analyses. Fourteen studies were conducted in high-income countries, eight in low-middle-income countries (LMICs). Ten studies were on asthma, nine on pneumonia, two on asthma and pneumonia, and one on tuberculosis. Quality assessment of the articles revealed some methodological inconsistencies across the articles. Conclusion Fewer EEs were conducted in LMICs, yet children from these countries are disproportionately affected by pulmonary diseases. Developing standardised methods for EEs and conducting more EEs and for paediatric pulmonary diseases in LMICs could allow for more evidence-based decision-making.
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    The cost of providing consultative palliative care services in a tertiary hospital setting
    (2020) Mbuthini, Linda; Cunnama, Lucy; Krause, René; Moodley, Jennifer
    Background The Sub-Saharan African region has sparse palliative care established to cater for patients facing life limiting conditions. In South Africa, costing frameworks for palliative care interventions for the public sector do not exist and the cost of running a comprehensive palliative care programme remains unknown. There are few costing studies to inform costs of palliative care models which are necessary for decision makers to base their decisions on. The aim of this study was to determine the costs and cost drivers for hospital based consultative palliative care service (HBPCS) in South Africa adopting a providers' perspective. Methods In this empirical costing study, we developed and utilised a costing tool that employed a mixed bottom-up and top-down costing method to estimate the incremental cost of an existing hospital based consultative palliative care services (HBCPCS) in a tertiary hospital in Cape Town, South Africa, called Groote Schuur Hospital (GSH) adopting a public provider perspective. All inputs where valued using bottom-up, ingredients-based methods, except for direct staff where a top-down approach was utilised to allocate the staff's full salary to palliative care services. We collected costing data by conducting inventory audits, key informant interviews and observations. All inputs required in the production of the HBCPCS were checked against a costing framework for economic evaluations of palliative care interventions to ensure that the cost estimates were as inclusive as possible. All inputs with a lifespan of more than one year were annuitized using a 3% rate. Results The total annual cost for running the HBCPCS was R2 494 419 including both recurrent and capital costs. Recurrent items alone accounted for 96% (R2 392 407). While capital items accounted for 4% (R102 013) during the study period. The total cost per visit was R642 including the standard drug treatment package (R16). The major cost driver in the service was personnel accounting or 91% of the total annual cost. While a scenario analysis shows that when the size of the team size is doubled then the cost of direct personnel would increase to R4.4 million. Conclusion We have estimated the incremental unit cost of HBCPCS to be R642 per visit, the major cost driver being personnel. If funding allows, with an annual cost of R2.4 million these services can be provided in a public tertiary hospital as an adjunct to inpatient care for patients as a strategy for integrating palliative care to general health care services, as has been done at GSH. The HBCPCS was less costly when compared to hospital-based outreach palliative care programmes.
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    The costing of COVID-19 intensive care units at a tertiary hospital in Cape Town, South Africa
    (2024) Hood, Kirsten; Joubert, Ivan; Cunnama, Lucy; Peters, Shrikant
    Background: The expansion of Groote Schuur Hospital's (GSH) Intensive Care Unit (ICU) capacity to accommodate an unprecedented number of patients during the COVID-19 pandemic was an expensive undertaking. There are currently no published formal retrospective analyses of the financial costs of running and expanding COVID-ICUs in South Africa. Objectives: To conduct a cost analysis of the COVID-ICU service at a tertiary state hospital in Cape Town, South Africa. This analysis included the cost of COVID-ICU admissions relating to the first four COVID waves. Aims were to estimate total costs, in-patient day costs, and cost drivers for COVID-ICU. Methods: A retrospective cost analysis (quantitative observational study) using a mixed methods costing approach, was conducted across the COVID-ICUs at GSH. The data used included two consecutive hospital financial years, between April 2020 and March 2022. Costs were calculated monthly and then combined to achieve a total cost over the two-year period. COVID-ICU in-patient days were used as the primary allocation factor. Cost inputs included recurrent costs such as human resources, diagnostics, pharmaceuticals, oxygen, enteral feeds, blood products, consumables, and overheads, as well as capital costs including equipment, and building space. Results: The study period covered the four COVID waves that affected GSH ICU units between April 2020 and March 2022. This period included 10 497 COVID-ICU in-patient days resulting from a total of 776 COVID-ICU admissions. The total calculated spending across the two financial years was R262 482 904, resulting in a cost per in-patient day of R25 006, and a utilisation of 4,4% of the total hospital budget during the same period. The median length of stay was nine days, resulting in a median cost per admission of R225 050. The top five cost drivers were human resources (60%), consumables (9%), pharmaceuticals (8%), oxygen (5%), and overheads (5%). Conclusion: This is a retrospective costing study of the COVID-ICUs at a tertiary hospital in Cape Town, throughout the entire portion of the pandemic that required ICU admissions in South Africa. This analysis provides useful financial insights, a potential economic model for ICU budgeting, and creates a platform for future economic analyses and policy planning regarding level-of-care decisions for general ICU admissions or for similar future pandemics within the South African and LMIC hospital setting.