Browsing by Department "Unknown"

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    A cost-utility and budget impact analysis of long-acting insulin analogues, (determir, glargine and degludec) for the treatment of adults with T1DM in South Africa
    (2023) Verryn, Mark; Cleary, Susan
    Background: Type 1 Diabetes Mellitus (T1DM) is a life-threatening condition that is managed with administered insulin. Intermediate- to long-acting insulin represents the basal insulin constituent of the total insulin used in treating T1DM and has received much research and development over the years. In South Africa, intermediate-acting Neutral Protamine Hagedorn (NPH) insulin has been the mainstay basal insulin recommended in the public sector. Newer (ultra) long-acting insulin analogues, however, have subsequently been approved for use. Costutility and budget impact analyses of the newer long-acting insulin analogues detemir, glargine and degludec have yet to be performed in the South African public health sector context. Methods: A systematic search for clinical evidence was performed to inform the economic evaluation. A cost-utility analysis was carried out utilising Markov modelling. Seven comparators were modelled representing the various insulin types and treatment regimens. For each comparator, three Markov states were created, one in which no complications occurred and another two states representing nocturnal and daytime hypoglycaemic events respectively. Three scenarios were modelled in order to capture the variable rates of complications reported in the clinical evidence. Quality-Adjusted Life Years per patient year was the health outcome utilised. Costs were included as South African Rands and then converted to United States dollars. A cost-effectiveness threshold range appropriate for the South African context was used to assess value for money. Thereafter, a budget impact analysis was conducted. Results: Three systematic reviews were identified in the systematic search for inclusion in this study. Subsequently, three scenarios were modelled in order to capture the clinical significance identified in the three systematic reviews. All three models favoured NPH insulin over the alternatives, as NPH insulin dominated most other insulins, barring insulin detemir, insulin glargine-U300 and insulin degludec. Insulin detemir was the most cost-effective option of the alternatives to NPH insulin (ICER of 10,783.75 USD/QALY). However, insulin detemir was still not cost-effective in relation to South Africa's cost-effectiveness threshold (CET 1,175 - 8,909 USD/QALY). The NPH insulin twice daily regimen was also found to dominate the NPH once daily regimen. Conclusions: The status quo of NPH insulin in the management of T1DM in adults remains the most cost-effective option for the South African public health sector. Further research and consideration could be made for the use of NPH insulin twice daily, as opposed to once daily.
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    A Retrospective, Observational Study of Medico-legal Cases against Obstetricians and Gynaecologists in South Africa's Private Sector
    (2020) Taylor, Bettina; Cleary, Susan
    South Africa is experiencing a medico-legal crisis that is threatening the delivery of essential health care services, especially relating to maternal and fetal health. In the private sector, professional indemnity premiums for obstetricians to provide insurance cover in the event of medico-legal challenges have increased more than 10-fold in a 10-year period. In the State, exponential increases in contingent liabilities for claims due to alleged negligence are usurping health care budgets allocated towards the delivery of health care, with about half of these claims relating to obstetrics and gynaecology and three quarter of latter to cerebral palsy for reasons of alleged hypoxic brain injury of the newborn. Despite the ominous implications of these developments for the supply side of health care, there is a scarcity of information in terms of contributing factors. Whilst many assume that the main driving force of burgeoning professional indemnity premiums for obstetricians and gynaecologists in the private sector have also been as a result of claims for cerebral palsy, there are no empirical data to explain developments over recent years and guide risk management interventions in this regard. To understand claim trends and identify potential predictors of patient dissatisfaction that result in engagement of the regulatory and legal system in the private sector, obstetric and gynaecological medico-legal data recorded by Constantia Insurance Limited, a local professional indemnity provider, were analysed. Other than confirming a steep increase in medico-legal notifications for obstetric- and gynaecology-related complaints from about 2003 to 2012, a high proportion of number of claims and paid settlements for gynaecology relative to obstetric-related cases was noted. This is contrary to international and public sector experiences, where number of demands relating to obstetrics consistently exceed those associated with gynaecological care. This finding, together with the fact that the majority of pay-outs on behalf of doctors related to surgical complications, especially unintended intraoperative injuries to internal organs and vessels, calls for further research into the clinical outcomes of private gynaecological practice, as well as potential review of aspects of surgical training standards and accreditation in gynaecology and consideration of surgical mentorship programmes. The latter is particularly relevant in the context of surgical registrars having expressed concerns about their readiness to practice independently following specialist graduation. Whereas claims for severe neurological injury of the newborn constituted less than 15% of all claims settled on behalf of obstetricians and gynaecologists entered into the study, they accounted for about half of all known paid settlements relating to pregnancy-related care. Whilst not dominating in terms of claim frequency overall, they nevertheless are an important focus area for risk management interventions, given the high quantum of demand typically associated with these cases. In this regard, more research into the etiology of errors is required, including the contribution of nursing and other system failures that could not be quantified adequately as part of this research project. Another important finding was the disproportionate contribution of medico-legal risk by a small cohort of practitioners, which suggests a need for doctor-focused support and interventions, including effective peer review and regulatory oversight by the Health Professions Council. To reverse the high financial burden of professional indemnity fees and fear of litigation amongst private sector obstetricians and gynaecologists, multidimensional risk management interventions, which include enhancements at the point of care, are required. If medicolegal trends and their negative consequences are to be reversed, medico-legal hotspots should become an important source of information and consideration in the development of solutions aimed at preventing human error and strengthening the healthcare system in terms of improved patient safety and satisfaction.
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    Cost benefit analysis of energy efficiency in low-cost housing
    (1999) Winkler, Harald; Fecher, Randall Spalding; Tyani, Lwazikazi; Matibe, Khorommbi
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    Cost utility and budget impact analysis of bortezomib and lenalidomide for the treatment of relapsed/refractory multiple myeloma in the South African public health sector
    (2021) Matsela, Lineo Marie; Cleary, Susan; Wilkinson, Thomas
    Multiple myeloma (MM) is the second most common haematologic cancer, accounting for approximately 13% of all blood cancer cases worldwide. The global incidence rate increased by 126% from 1990 to 2016. In South Africa, multiple myeloma accounts for approximately 9% of haematological cancers and less than 1% of all cancers. Nevertheless, some studies have reported that the incidence is likely underestimated due to an underdiagnosis of the cancer. Thus, the disease could possibly be an issue of greater concern in South Africa than current statistics indicate. The nature of the MM tumour makes patients prone to resistance of chemotherapy and multiple relapses leading to the development of relapse/refractory multiple myeloma (RRMM). During the relapse/refractory period, the patient is nonresponsive to treatment and/or experiences progressive disease When a patient experiences relapse/refractory MM, their prior, (first line) treatment is readministered if it was clinically efficacious and well-tolerated. Contrarily, a change in regimen is recommended if “an insufficient response, a rapid relapse and poor tolerance” to the first-line treatment is experienced by a patient. Second-line regimens that are recommended due to their proven high clinical efficacy are lenalidomide plus low-dose dexamethasone (LEN/DEX) and bortezomib monotherapy (BORT). The clinical effectiveness of both regimens for second-line treatment of RRMM was reported in the MM009/010 and the APEX studies, respectively, where each regimen was compared against dexamethasone monotherapy. Given this proven clinical effectiveness for RRMM, lenalidomide is under consideration for inclusion in the South African Essential Medicines list. Three treatment strategies for second line RRMM treatment were modelled from a provider's perspective. These strategies were dexamethasone (standard of care), BORT and LEN/DEX. For each strategy we modelled a hypothetical cohort of relapsed/refractory multiple myeloma patients using a three-state Markov model (pre-progression, progression and dead) over a 15-year time horizon. Efficacy data was obtained from the MM009/010 and APEX trials, while utilisation rates were obtained from a European study. Other input data was sourced from local literature. Outcomes were reported in quality adjusted life years (QALYs). Incremental cost effectiveness ratios (ICERs) were calculated for BORT and LEN/DEX and compared to the local cost-effectiveness threshold to determine if the drugs are good value for money for the South African government. The total costs per patient using DEX, BORT and LEN/DEX over 15 years differed significantly resulting in estimates of R8 312.32, R234 995.50 and R1 135 323.37, respectively. The associated health benefits in terms of quality-adjusted life years gained from the treatments were 1.14, 1.49 and 2.29. Hence, for every quality adjusted life year gained from BORT relative to DEX, an additional R654 648.52 would need to be spent. In contrast, when BORT is compared to LEN/DEX, an additional R1 225 542.23 would need to be spent for an additional quality adjusted life year gained from LEN/DEX. Both the BORT and LEN/DEX treatments were not cost-effective relative to the costeffectiveness threshold of R38 500 per DALY gained. Due to the high costs, both BORT and LEN/DEX could potentially have significant economic impacts on the South African public health sector budget. The study suggests that one year of treatment for 337 RRMM patients in South Africa using the BORT and LEN/DEX would increase the budget budget-cost of RRMM treatment by 3136% and 8684%, respectively. Both BORT and LEN/DEX treatments would not be cost-effective strategies for second-line treatment of RRMM in South Africa. The results indicate that the drug prices of lenalidomide and bortezomib hinder the cost-effectiveness of BORT and LEN/DEX. Price reductions could potentially make BORT more cost-effective and allow it to be considered as an option for second-line treatment for RRMM patients.
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    Evaluation of a common method of convulsion therapy in Bantu schizophrenics
    (1955) De Wet, Jacobus Stephanus du Toit
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    Exploring the interplay of ecological and social factors in human-induced disturbance of the African Oystercatcher (Haematopus moquini): insights and management recommendations for conservation
    (2023) Keet, Taylor; Anderson, Pippin; Altwegg Andreas
    It is well-established that nature-based recreation can pose a significant threat to wildlife. However, certain activities may have greater impacts than others, such as dog walking. Estuarine and coastal ecosystems are frequented by dog walkers, and they are also home to shorebird populations that are facing mounting pressure due to human disturbance. African Oystercatchers (Haematopus moquini) are vulnerable to human disturbance because they are a ground-nesting species that breeds during the height of the South African holiday and tourist season (October-March). Domestic dogs (Canis familiaris) are heavily implicated in the lower breeding success rates evident in mainland African Oystercatcher populations. Therefore, this research focussed on both the ecological (flight initiation distances) and social dimensions (beach user surveys) of human disturbance of African Oystercatchers. The results of the ecological dimension showed that treatment type (dog vs. no dog treatment), location, incubation status, and the interaction between location and incubation status had a significant effect on African Oystercatcher flight initiation distances. Most importantly, African Oystercatchers had longer flight initiation distances on average in response to the dog treatment (a walker approaching with a leashed dog) compared to the no dog treatment. The results of the social dimension revealed ‘ambivalence' and ‘contradiction' themes. The ambivalence theme centred around the recreationists being uncertain about or disliking the majority of the hypothetical regulations aimed at protecting shorebirds, despite strongly agreeing that shorebird protection and regulations are important. The contradiction theme centred around two sub-themes. Firstly, the species literacy gap that emerged when the recreationists agreed that they were familiar with local shorebirds, while being unable to substantiate this belief by naming the species. Secondly, the cognitive dissonance displayed by the recreationists when they showed good awareness of the threats that human activities pose to shorebirds, while also strongly agreeing that their dogs pose no threat, and many also indicating that larger buffer zones are required to protect shorebirds from dog walkers. Three evidence-based management recommendations were provided, namely implementing buffer zones during the breeding season, tackling the poor leashing compliance rate, and installing signage to educate recreationists and persuade them to adopt pro-social behaviours.
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    Farm labour on the Zebediela estates
    (1971) Stapelberg, J P M
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    Gynaecological case book.
    (1957) Du Toit, Pierre Francois Mulvihal
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    Mechanisms of Impaired Diuretic responsiveness in Chronic Heart Failure
    (1997) Salusbury-Trelawny, Joanna Mary
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    On farms and in laboratories: maize seed technologies and the unravelling of relational agroecological knowledge in South Africa
    (2021) Marshak, Maya; Wynberg, Rachel; Wickson, Fern
    When Europeans settled in South Africa in the 17th century, maize was already being grown as part of diverse and traditional cropping systems. Over centuries maize has become embedded in a web of social, ecological, economic and political relations. Since the 1900s the development of maize seed has increasingly shifted location as scientific maize breeding has come to dominate its production. In this time maize seed has changed form, from open pollinated varieties (OPVs) to hybrid seed, and most recently to genetically modified (GM) seed. While the progression of seed developments alongside their co-technologies such as pesticides, fertilizers and herbicides has greatly boosted yields, the development of maize has become increasingly generic and disconnected from the specificities of local agroecosystems. Like all technologies, maize seed technologies are not neutral but are rather deeply entangled in the history and politics of knowledge production. Commercial technologies such as hybrid and GM seeds are products of a particular lineage of thought rooted in the post-enlightenment age of modernist, dualist science. This has resulted in a conceptual dualism in which humans are seen as separate from nature. Studies on the impacts of new seed technologies have tended to replicate this dualism, focusing either on social or ecological aspects. Few investigate the effects on relationships between humans and agro-ecosystems. This thesis aims to address this knowledge gap by exploring the effects of the technification of maize seed on knowledge and practices within two sites of agricultural knowledge generation and practice in South Africa: smallholder maize agriculture and maize research and development. These offer two unique sites of knowledge creation and practice, and historically have had a turbulent relationship, rooted in colonialism and apartheid histories. Through exploring human-agroecosystem interactions, the research hopes to contribute to a broadened understanding about the impacts of maize seed technification and implications for agricultural knowledge generation and sustainability. Drawing conceptually and methodologically on posthumanist theory, this thesis investigates the changing nature of social-ecological relationships of and between smallholder farmers and scientists and the agro-ecological systems in which they work. Building on the concept of agricultural deskilling, it argues that modern seed technologies have contributed to ecological deskilling both on smallholder farms and within research and development, as seed technologies become increasingly disconnected from the environments in which they are used. 2 Increasingly, however, there is renewed interest by both farmers and scientists in ecological-reskilling as new ‘silver bullet' seed technologies reveal many setbacks. The thesis concludes that in order to rebuild displaced ecological knowledge an ontological shift is needed to move beyond dualist science-based approaches to farming and research, towards those that learn from relational ways of knowing. Approaches should be embraced that acknowledge the relational knowledge of smallholder farmers that has been displaced and devalued for centuries and that builds this relationality into research. This c could contribute to restoring cognitive justice and fostering more resilient agricultural futures.
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    Personnel management in the South African Railways
    (1947) Seawright, Thelma Rosa
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    Post-operative wound infection
    (1947) Schulze, W G
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    Rural Energy and Development: improving energy supplies for 2 billion people: a World Bank best practice paper (Draft)
    (1996) World Bank
    This paper envisages a renewed commitment by the World Bank to support its member countries' efforts to extend modem energy supplies to populations still without them and to promote the sustainable supply and use of biofuels for as long as they remain important sources of energy. Modem energy is defined to include new forms of renewable energy. The purposes of the paper are threefold. First, it argues why meeting the energy needs of rural-and also unserved urban- populations is a priority for sustainable economic development. Second, it reviews twenty-five years of experience with rural energy programs in developing countries; it finds that notwithstanding some mistakes, in any approaches are working well and provide an excellent basis for a substantial expansion of effort to address rural energy problems. Third, it seeks to disseminate and share these lessons of experience with others on whom much responsibility will fall for the implementation of policies; indeed, the preparation of the paper itself entailed extensive sharing of experiences between representatives of the Bank, industry, and numerous governmental and nongovernmental organizations.
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    Socioeconomic inequities of malaria prevalence in under-five children in Ghana between 2016 and 2019
    (2024) Edusei, Marian; Alaba, Olufunke
    Background Globally, malaria is a preventable and treatable disease that still accounts for thousands of deaths annually, putting approximately 3.3 billion people at risk. Children under five are the most affected, with Sub-Saharan Africa bearing the highest burden. In Ghana, malaria causes nearly 20,000 child deaths each year, a quarter of which are in children under five. Although the association and socioeconomic inequalities related to malaria prevalence have been studied, there is limited evidence on socioeconomic status (SES)-related inequality in malaria prevalence among Ghanaian children under five. Understanding these inequalities is crucial for Ghana to advance towards its sustainable developmental goals (SDG) 10, which focuses on reducing inequalities, and SDG 3, which promotes health and well-being. Methods The study adopts a literature review structured into theoretical, methodological, and empirical sections. It discusses the economic burden of malaria and defines theoretical frameworks for SES-related inequalities, using the commission of social determinants of health (CSDH) framework as the conceptual foundation. Methodologies for measuring SES-related inequalities and methods for decomposition analysis are reviewed. Using the period between 2020-2024, the empirical review focused on socio-economic related inequalities in malaria. The 2016 and 2019 Ghana malaria indicator survey datasets were analysed using Stata 15. The outcome variable was malaria prevalence in under-five children, explanatory variables included socio-economic status (household wealth), age of child, mother's education, place of stay, region and a few others. Our study applied the concentration indices and curves to assess socioeconomic inequalities in malaria prevalence among under-five children and decomposing the concentration index to identify contributing socioeconomic factors. Results The 2019 concentration index was significantly negative (CI= -0.224; SE=0.059), indicating a higher prevalence of malaria in children from lower socioeconomic backgrounds. While the 2016 index was not statistically significant, it was still negative, suggesting a pro-poor bias in malaria prevalence (CI= -0.052; SE= 0.053). The decomposition analysis found that wealth index, region, and ethnicity were significant contributors to the observed inequalities, accounting for 59.28%, 23.51%, and 4.15% of them, respectively, in 2019. Conclusion There are pro-poor inequalities in malaria prevalence among under-five children in Ghana, with a higher burden on those from lower SES backgrounds. Malaria intervention programs should be tailored to target these vulnerable populations and regions that are disproportionately affected by the disease to effectively combat malaria and advance toward meeting the SDGs related to health and inequality.