Only 16% of South Africans can afford private healthcare, and many low-income earners cannot afford healthcare and must rely on community clinics. These facilities are under intense pressure as they often cannot cope with the demand. For many workers, getting medical attention at these facilities means waiting for hours and being unable to work for a day and therefore losing wages. However, things could change if the pioneering efforts of a dedicated nurse with the financial backing of Standard Bank reach their full national potential.
“We assist this sector by working longer hours than do local government clinics that only open five days a week. Our services are available seven days a week at R300 per visit. Those able to pay for primary healthcare often must travel long distances to get to pharmacy-based primary healthcare clinics, mostly in the suburbs. The Rapha Clinic has been strategically placed between the city and the townships so that it can be easily reached by people commuting from their homes to the city,” says Ntombi Skosane, founder of Rapha Healthcare Services.
For Skosane, the clinic, which is located in the Montana area of Pretoria, realised her dream of being able to fill a vital gap in providing primary and basic healthcare to her community.
“As a nurse with 30 years in both the public and the private sector, I believed that I could open a clinic where I could establish a community service offering quality healthcare at affordable rates. The growing success of our operation shows that I was correct,” she adds.
Using her experience of clinics as a guide, Skosane has opted to have Rapha offer nine core services ranging from antenatal care and family planning to assisting with immunisations and wound care, as well as helping those with chronic illnesses and HIV testing and counselling.
“The Rapha Clinic met the stringent guidelines for being considered for a grant. These included an assessment of the viability of the business by the Standard Bank Enterprise Development Funding Committee, the commitment and required personal investment of the owner, and the sector in which the business operates. Although the business was operating successfully, it needed financial assistance to reach its full potential. In this case, the company needed additional stock and equipment to deliver a full service. After considering the application, Standard Bank purchased the required equipment for Rapha,” says Naledzani Mosomane, Head of Enterprise and Supplier Development at Standard Bank.
Skosane says that acquiring additional medical and surgical stock, emergency trollies, a vaccine fridge, wheelchairs, and air-conditioning through Standard Bank meant that the clinic would be able to attend to more patients more efficiently.
Rapha may be just a single clinic, but new outlets are being planned for Gauteng and the North West Province. Ten new clinics are being considered, as are health assessment centres in partnership with gyms and medical aids.
“We believe that Rapha Healthcare Services has a bright future. We look forward to playing a central role in growing the nation’s small business sector and developing relationships with a new generation of entrepreneurs,” says Mosomane.
Women who have their ovaries removed before menopause, particularly before the age of 40, have reduced white matter integrity in multiple regions of the brain later in life. The findings appear online in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.
“We know that having both ovaries removed before natural menopause causes abrupt endocrine dysfunction, which increases the risk of cognitive impairment and dementia,” said Michelle Mielke, PhD, professor at Wake Forest University School of Medicine. “But few neuroimaging studies have been conducted to better understand the underlying mechanisms.”
For the study, the research team examined data from the Mayo Clinic Study of Aging to identify women over the age of 50 with available diffusion tensor imaging, a magnetic resonance imaging (MRI) technique that measures white matter in the brain. The cohort was comprised of:
22 participants who had premenopausal bilateral oophorectomy (PBO) before age 40
43 participants who had PBO between the ages of 40 and 45
39 participants who had PBO between the ages of 46 and 49
907 participants who did not have PBO before the age of 50
“Females who had premenopausal bilateral oophorectomy before the age of 40 had significantly reduced white matter integrity in multiple regions of the brain,” said Mielke, the study’s corresponding author. “There were also trends in some brain regions such that women who had PBO between the ages of 40–44 or 45–49 years also had reduced white matter integrity, but many of these results were not statistically significant.”
Mielke said that 80% of participants who had their ovaries removed also had a history of oestrogen replacement therapy. Therefore, the study was not able to determine whether the use of oestrogen replacement therapy after PBO mitigated the effects of PBO on white matter integrity. She noted that the ovaries secrete hormones both before (primarily oestrogen, progesterone and testosterone) and after menopause (primarily testosterone and androstenedione).
“Having both ovaries removed results in an abrupt decrease in both oestrogen and testosterone in women,” Mielke said. “Therefore, one possible explanation for our results is the loss of both oestrogen and testosterone.”
Mielke said additional research is needed to further understand how white matter changes are associated with cognitive impairment.
“While these findings are important for women to consider before having premenopausal bilateral oophorectomy for non-cancerous conditions, we need a larger and more diverse cohort of women to validate these results.”
Pancreatic cancer. Credit: Scientific Animations CC BY-SA 4.0
Patients with pancreatic cancer who received chemotherapy both before and after surgery experienced longer survival rates than would be expected from surgery followed by chemotherapy, according to a new study from researchers at Yale School of Medicine.
The study, published June 20 in JAMA Oncology, included patients with pancreatic ductal adenocarcinoma (PDAC), an aggressive cancer with a high mortality rate which accounts for 90% of pancreatic cancers. The researchers say these findings are encouraging for the 15 to 20% of patients with operable pancreatic cancer.
The single-arm Phase II trial evaluated a modified form of the chemotherapy treatment FOLFIRINOX. This combination treatment consisting of leucovorin calcium, fluorouracil, irinotecan hydrochloride, and oxaliplatin received US Food and Drug Administration approval in 2011 as a first-line treatment for patients with metastatic pancreatic cancer. Patients in the trial received six cycles of the modified FOLFIRINOX before surgery, followed by an additional six cycles of the chemotherapy treatment after surgery. The modified regimen consisted of slightly lower doses of FOLFIRINOX to improve tolerability, which was previously shown in a 2016 publication not to impact outcomes negatively.
Of the 46 patients who started the modified treatment, 37 completed all six cycles of chemotherapy before surgery and 27 had successful tumour removal operations. For all enrolled patients, the 12-month progression-free survival rate was 67%, indicating significant progress in controlling the disease. Furthermore, 59% of all patients lived at least two years after completing the full chemotherapy treatment plan and surgery.
The study was the first of its kind for patients with PDAC when senior author and Yale Cancer Center member Jill Lacy, MD, started it in 2014. The study goal had been a 12-month progression-free survival rate of at least 50% of patients.
“When the study launched, even with operable pancreatic cancers, 90% of patients were still relapsing and dying from their cancer eventually,” said Michael Cecchini, MD, the first author of the study. “We sought to move chemotherapy up in their treatment regimen and give it before surgery to see if we could improve the outcome for our patients.”
The study used advanced techniques to monitor the progress of treatment, including analysing circulating tumour DNA (ctDNA) and using the cancer biomarker keratin 17 to help predict outcomes. For example, patients with detectable ctDNA four weeks post-surgery had significantly worse progression-free survival than those who had no detectable ctDNA.
Cecchini said larger randomised clinical trials are needed to continue to investigate the role of FOLFIRINOX before surgery for patients with operable PDAC.
“I think even though there have been changes in standard of care for patients with this aggressive pancreatic cancer type, we have here very promising data to justify a larger study,” said Cecchini.
Credit: Darryl Leja National Human Genome Research Institute National Institutes Of Health
A new study published in Neurology suggests that certain drugs commonly used to treat enlarged prostate may also decrease the risk for dementia with Lewy bodies (DLB). This observational finding may seem surprising, but it mirrors previous work by the University of Iowa Health Care team that links the drugs to a protective effect in another neurodegenerative condition: Parkinson’s disease.
The UI researchers think that a specific side effect of the drugs targets a biological flaw shared by DLB and Parkinson’s disease, as well as other neurodegenerative diseases, raising the possibility that they may have broad potential for treating a wide range of neurodegenerative conditions.
“Diseases like dementia with Lewy bodies, or Parkinson’s disease, or Alzheimer’s disease are debilitating, and we don’t really have any good treatments that can modify the disease progression. We can treat symptoms, but we can’t actually slow the disease,” explains lead study author Jacob Simmering, PhD, UI assistant professor of internal medicine. “One of the most exciting things about this study is that we find that same neuroprotective effect that we saw in Parkinson’s disease. If there is a broadly protective mechanism, these medications could potentially be used to manage or prevent other neurodegenerative diseases.”
Large observational study links prostate drugs to lower risk of dementia with Lewy bodies
DLB is a neurodegenerative disease that causes substantial and rapid cognitive decline and dementia. It affects about one in 1000 people per year, accounting for 3 to 7% of all dementia cases.
For the new study, the UI researchers used a large database of patient information to identify more than 643 000 men with no history of DLB who were newly starting one of six drugs used to treat benign prostatic hyperplasia (enlarged prostate).
Three of the drugs, terazosin, doxazosin, and alfuzosin (Tz/Dz/Az), have an unexpected side effect; they can boost energy production in brain cells. Preclinical studies suggest that this ability may help slow or prevent neurodegenerative diseases like PD and DLB.
The other drugs, tamsulosin and two 5-alpha-reductase inhibitors (5ARIs) called finasteride and dutasteride, do not enhance energy production in the brain and therefore provide a good comparison to test the effect of the Tz/Dz/Az drugs.
The team then followed the data on these men from when they started taking the medication until they left the database or developed dementia with Lewy bodies, whichever happened first. On average, the men were followed for about three years.
Because all the participants were selected to start a drug that treats the same condition, the researchers reasoned that the men were likely similar to each other at the outset of the treatment. The men were all propensity score-matched for characteristics like age, year of medication start, and other illnesses they had before starting the treatment, to further reduce the differences between the groups.
“We found that men who took Tz/Az/Dz drugs were less likely to develop a diagnosis of dementia with Lewy bodies,” Simmering says. “Overall, men taking terazosin-type medications had about a 40% lower risk of developing a DLB diagnosis compared to men taking tamsulosin, and about a 37% reduction in risk compared to men taking five alpha reductase inhibitors.”
Meanwhile, there was no statistically significant difference in risk between men taking tamsulosin and alpha reductase inhibitors.
Approved drugs show potential
Since this was an observational study, causation cannot be established, only an association. In addition, the study only included men because the drugs are prescribed for prostate problems, which means that the researchers don’t know if the findings would apply to women. However, Simmering and his colleagues are excited by the potential of these drugs, which are already FDA approved, inexpensive, and have been used safely for decades.
“If terazosin and these similar medications can help slow this progression – if not outright preventing the disease – this would be important to preserving cognitive function and quality of life in people with DLB,” Simmering says.
Is complementing in-person care with virtual care (hybrid care) a key part of the answer to South Africa’s NHI aspirations, asks Deon Bührs, Managing Director of Genie Health SA, who suggests that technology is the ‘unreasonable man’ in complementing decent universal healthcare and that self-empowerment is the only solution to sustainable wellness.
“The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
George Bernard Shaw
There is a school of thought that a young democracy can benefit from a well-considered blend of socialism and capitalism, particularly when it comes to healthcare and education. I would second that, to a degree. That South Africa requires a more equitable health system goes without saying though, as the apparent disparity and divisions between the haves and have nots is ever widening.
The status of our public healthcare system and the spiralling costs of the private offering need to find parity. A sad situation indeed, because at one stage, South Africa had one of the best public health sectors in the world, where groundbreaking heart transplants, for example, were done.
To the question of universal healthcare then. If it means that universal healthcare is a fundamental human right that everyone should aspire to, then it’s a yes, the NHI is essential. It should not be a matter of political affiliation, and let’s be clear, there is already healthcare for all in South Africa, through the public health system, free at the point of care for those who cannot afford care. But it is the quality of this care, and the effective management of these services that lie in stark contrast to that of the private healthcare system.
Signed in literally at the 11th hour before the country went to general elections, the National Health Insurance (NHI) bill is a polarising topic for many. The massive cost of providing a functioning NHI as per the bill, has been estimated conservatively at more than R200 billion a year, while some estimate closer to R1 trillion. With an already strained tax base, we must adopt new thinking as to how to deliver healthcare in a cost sensitive and effective way.
To my mind, one of the most effective ways of ensuring there is universal care that works, is recognising and supporting the role the patient plays in empowering their own health, recovery and wellness journey. They appear, however, to have been forgotten in the conversation that is the NHI bill to date.
For me, in its current guise, the NHI will unfortunately not bridge the quality divide. In fact, if we are not careful and if we do not find common ground, and hold government and the private sector to account, our entire healthcare system could well be in danger of failing – completely.
The unreasonable man test – laying the groundwork for new ways of healthcare delivery
Although expediently signed into law with little regard to comments or concerns raised from many sectors including health and business, the NHI does lay the groundwork for new ways of delivering healthcare and sets the scene for changing the mindset from the current sick-care system mentality to one of a patient-empowered HEALTHcare system.
Change must happen, but the extent of that change often depends on what Irish playwright and political activist, George Bernard Shaw, once stated as: “The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
At present, Prof Nicholas Crisp who has been tasked with helming the delivery of the NHI, could be seen as Shaw’s “unreasonable man” in his efforts to equalise and deliver universal healthcare. Ensuring that the lever of technology is utilised in an effective way is critical though, to ensure that we don’t try and replicate previous perceived successes, and not move forwards.
With a challenged healthcare system, both public and private, we are called to not give up hope, but to lean into the solution, and at the same time, avoid a defensive posture of that which only served the few. I believe that these circumstances force us to innovate, and to seriously consider new ways of providing healthcare for all. It should be seen as an exciting time of just where we can push the future of healthcare.
For instance, we already know that a traditional healthcare delivery system, with its associated costs and accessibility challenges for those living in remote parts of our country just won’t cut it. But unlocking technology as the new delivery channel of healthcare complimented by affordable and fast internet, could well be the solution to cracking the code of healthcare for all.
Through technology we can drive the patient-centric approach to health and open the door for patients to more easily access the multi-disciplinary team of healthcare professionals they need.
The best of both worlds – prevention, and when required, recovery
An example of doing things differently, is a new approach to musculoskeletal health that has been facilitated by digital transformation, and which is finding growing adoption in South Africa. With objective improvements in patient outcomes, satisfaction scores and recovery times, virtual care teams can support patients through their recovery programmes, ensuring improved compliance and ownership of their health journey. And empowering patients to embrace exercise and activity over surgery and pharmaceuticals where appropriate, has a dramatic impact on the overall healthcare spend.
Imagine patients having the choice to access a multi-disciplinary team of experts anywhere in the country – from the comfort and convenience of their own home or workplace, all at the tips of their fingers. No need to be transported to a clinic or hospital every time they need healthcare services. This is entirely possible, with platforms like Genie Health, that provide a hybrid approach in complimenting in-person care with virtual care.
NHI needs a strong front loader like these hybrid platforms that provide the full range of allied healthcare services, to reduce the burden of care and cost on an already strained system, by reducing unnecessary hospital admissions, surgeries, medication and travel costs and allowing for the existing framework to be brought up to date and even surpass expectations.
With ICASA reporting over 75% of the population having Internet access in South Africa and more than 90% smartphone penetration, pressure on Mobile Network Operators to provide zero rated data for healthcare applications (as they have done in education and other areas) mounts.
If measures like this can be implemented, they will have a tremendous impact on reducing the burden on the existing healthcare system through a self-health-empowered approach, with the backing of a full clinical team on the ready to assist the patient.
The ultimate question is how do we make healthcare more affordable and accessible to all South Africans, which is the core aim of the NHI?
The answer – we need to renew our focus on the key stakeholder, our patients – and empower them to drive their own health, by using technology as the backbone for sustainable wellness. It could well be, that with a renewed mindset and health-empowered citizens, the NHI is the true gamechanger for progress in HEALTHcare that we all need.
