South African Private Health Sector Research Articles

The scope of childhood cancer in South Africa: A response to 'Childhood cancers in a section of the South African private health sector - Analysis of medicines claims data'.

Childhood cancer is an under resourced medical field that is emerging as a great healthcare concern in low- and middle-income countries such as South Africa. Therefore, reporting data in this field that may inform policymakers should be representative of the subject matter. This article aims to discuss why medicines claims as an indicator for incidence, as per an article published in 2020, is not representative of childhood malignancies in the South African setting. Literature to support the commentary were sourced using Pubmed, Google scholar, and data presented by members of the South African Children’s Cancer Study Group (SACCSG). Private medical aid coverage in South Africa between 2002 and 2018 varied between 15.5% and 18.2%. Of these, 9.5% were children under 18 years and 3.5% were under the age of six. Only 13.5% of children were treated in private paediatric oncology units during 2015. The limitations in the study were the variable medical aid coverage, the disproportionate age representation, and lack of reliable indicators for measurement and calculation of incidence. Utilising one medicines claims data base to evaluate the incidence of childhood cancer in South Africa is not representative and cannot inform policy.ContributionThis article highlights the importance of accurate registration of childhood cancer diagnoses, especially when data and conclusions based on these results inform policy. The study highlights the limitations of extrapolating general conclusions based on data representing only a small sector of the childhood cancer landscape in South Africa.

Coexisting Conditions among Children and Adolescents with Cancer in a Section of the South African Private Health Sector: Perspectives from Drug Utilization Data

Coexisting conditions are relatively common in children with cancer, however, there is a paucity of information on the prevalence of coexisting conditions in children with cancer in South Africa. This cross-sectional study aimed at investigating the common coexisting conditions occurring in children and adolescents younger than 19 years undergoing cancer chemotherapy in a section of the South African private health sector. Medicine claims data from 1 January 2008 to 31 December 2017 were queried to identify coexisting conditions using the International Classification of Diseases, Tenth Revision (ICD-10) codes indicated on reimbursed claims. Where ICD-10 codes per claim were non-specific, the pharmacological drug classes of non-cytotoxic medications claimed alongside these codes were categorized using the Monthly Index of Medical Specialties (MIMS) classification system and analyzed using the drug utilization 90% (DU90%) principle. Analysis of sub-pharmacologic drug classes was stratified according to gender and age groups. The reimbursement category of these medicines was noted. Data were analyzed descriptively. A total of 173 participants were included in the study. ICD-10 codes were available for 13.65% (N = 2631) of medicine claims. Diseases of the respiratory system (J00–J99, 7.15%), gastrointestinal tract (K00–K95, 1.60%), and skin disorders (L00–L99, 0.95%) were the most prevalent specific diagnoses identified. Non-specific ICD-10 codes were recorded on 86.35% (n = 2272) of non-cytotoxic medicine claims. The most frequently utilized pharmacological classes of medications included antimicrobial agents (17.40%), respiratory system agents (13.91%), and analgesics (10.64%). As determined from ICD-10 codes and medication claimed on reimbursed claims, children and adolescents being treated for cancers mostly suffered from acute conditions, in particular, microbial infections and diseases of the respiratory system. This indicates the need for the integration of antimicrobial surveillance programs into childhood and adolescent cancer care to curb antimicrobial infections.

Childhood cancers in a section of the South African private health sector: Analysis of medicines claims data.

BackgroundAlthough childhood cancers are rare, increases in incidence have been observed in recent times. There is a paucity of data on the current incidence of childhood cancers in South Africa.AimThis study described the epidemiology of childhood cancers in a section of the private health sector of South Africa, using medicines claims data.SettingThis study was designed on a nationally representative medicine claims database.MethodA longitudinal open-cohort study employing children younger than 19 years and diagnosed with cancers between 2008 and 2017 was conducted using medicine claims data from a South African Pharmaceutical Benefit Management company. Cases were identified using International Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes C00 to C97, together with a medicine claim reimbursed from oncology benefits. Crude incidence rates were calculated per million persons younger than 19 years on the database and standardised using the Segi 1960 world population. Temporal trends in incidence rates, analysed using the joinpoint regression, were reported as annual percentage changes (APCs).ResultsOverall, 173 new cases of childhood cancers were identified in the database, translating into an age-standardised incidence rate (ASR) of 82.3 per million. Annual incidence of cancer decreased from 76.7 per million in 2008 to 58.2 per million in 2017. More incident cases were identified in males (68.8%). The highest proportion of incident cases was recorded for leukaemias (39.9%), the 5–9 year age group (34.1%) and the Gauteng Province (49.7%).ConclusionThe incidence of childhood cancers decreased over time in the section of the private health sector studied. Leukaemias were the major drivers of childhood cancer incidence.

The Competition Commission Health Market Inquiry Report: An overview and key imperatives.

The Competition Commission's Health Market Inquiry (HMI) is the most systematic and comprehensive investigation carried out into the South African private health sector. The recommendations as set out in the HMI Final Report merit extensive discussion and debate, as they could - if implemented - have far-reaching consequences for the future of the healthcare system. The objective of this article is to contribute to this discussion by providing an overview of the key findings and recommendations of the HMI and highlighting the resultant key imperatives at this critical juncture of policy development.

The impact of generics and generic reference pricing on candesartan and rosuvastatin utilisation, price and expenditure in South Africa

Background In the South African private sector context, generically similar products are grouped together and the reimbursement rate is set at the average price of the generically equivalent products. Very little evidence exists in low and middle-income countries with regards to the impact of this policy over time. Objectives To determine the impact of the introduction of generics and generic reference pricing on candesartan and rosuvastatin in the South African private health care sector in terms of medicine utilisation, medicine price and medicine expenditure. Setting South African private health sector. Method Medicine claims for candesartan and rosuvastatin was obtained from a Pharmacy Benefit Manager in South Africa. The claims covered a 48-month period from January 2012 to December 2015 and provided a pre- and post-reference price period for analysis. Medicine utilisation was measured as the number of Defined Daily Doses dispensed per 100,000 beneficiaries. Medicine price and expenditure was calculated as the average per Defined Daily Dose. Main outcome measure Medicine utilisation, price and expenditure. Results Candesartan experienced an average 7.0% year-on-year decline in utilisation and rosuvastatin a 5.0% increase. Medicine expenditure reduced by an additional 34.6% and 20.9% for candesartan and rosuvastatin respectively. The total savings was 54.8% for candesartan and 31.9% for rosuvastatin. Conclusion The introduction of generics and generic reference pricing did not have an impact on medicine utilisation, but reduced the price and expenditure of both candesartan and rosuvastatin.

Antirheumatic Medicine Prescribing Patterns and Direct Medicine Costs in the South African Private Health Sector

To describe antirheumatic medicine prescribing patterns and to estimate the total annual direct medicine cost of rheumatoid arthritis (RA) in the private health sector of South Africa. A retrospective, cross-sectional drug utilization study was performed on medicine claims data from January 1, 2014, to December 31, 2014, for a total of 4,352 patients with RA. Patients were divided into those with RA only and those with RA and other chronic disease list conditions. Antirheumatic treatment was categorized into bridge therapy (nonsteroidal anti-inflammatory drugs [NSAIDs] and corticosteroids only) and therapy for advanced disease (NSAIDs, corticosteroids, and disease-modifying antirheumatic drugs [DMARDs] or biologics). Cost-driving products, the 90% drug utilization (DU90%) segment, mean, and median medicine item costs were calculated. Annual direct RA medicine cost summed to €4,115,569.70. The mean ± SD (median) cost per medicine item was €45.87 ± €250.35 (€9.01). DMARDs represented 47.6% (n = 42,699) and biologics 2.4% (n = 2,150) of the 89,728 medicine items claimed. The DU90% of bridge therapy products accounted for 92.8% of the total medicine cost, with celecoxib as the main cost driver because of high volume and mean cost. The therapy for advanced disease DU90% segment accounted for 34.7% of the total medicine cost, with adalimumab as the main cost driver because of high mean cost. The direct medicine treatment cost of RA in the South African private health sector is driven by the high volume of DMARDs and the high mean costs of biologics, particularly adalimumab.

Cost-savings accruable to removing value added tax from antiretrovirals in the South African private health sector

Background: Despite the important and essential role that medicines play in any society, all medicines, including those identified as essential, are uniformly subjected to 14% value added tax (VAT), regardless of their therapeutic value in the private healthcare sector of South Africa. The aim of this article is to demonstrate the potential cost-saving attained from the removal of VAT from the private sector pricing of essential medicines, using antiretroviral treatment as an example.Methods: An empirical analysis was undertaken to illustrate the potential cost-saving achieved by removing VAT from the Single Exit Price and the dispensing fee of essential medicines. This outcome was demonstrated by applying the methodology to an adult fixed dose combination 1st line antiretroviral regimen as well as to a group of 3rd line antiretroviral medicines.Results: The potential saving for the lowest priced generic and originator 1st line antiviral regimen accrued to ZAR 693.84 and ZAR 1085.04 over a year respectively. Regarding the 3rd line antiretroviral drugs, results yielded an annual saving of ZAR 1678.68 (darunavir), ZAR5741.04 (maraviroc) and ZAR 159.48 (rilpivirine).Conclusions: Lobbying for the removal of VAT from the supply chain of medicines should be intensified. Policy development to monitor and recover lost government revenue through the removal of taxes should be explored.

Prevalence of potentially serious drug-drug interactions among South African elderly private health sector patients using the Mimica Matanović/Vlahović-Palčevski protocol.

To determine the prevalence of potentially serious drug-drug interactions (DDIs) and their relationship with gender and age, among elderly in South Africa. A cross-sectional study was conducted using pharmaceutical claims data for 2013, for a total of 103 420 medical scheme beneficiaries' ≥65 years. All medications dispensed within one calendar month where the days' supply of medication dispensed overlapped, were grouped as one prescription. DDIs per prescription were then identified using the Mimica Matanović/Vlahović-Palčevski DDI protocol. Results were interpreted using effect sizes, that is Cramér's V, Cohen's d and Cohen's ƒ2 . A total of 331 659 DDIs were identified on 235 870 (25.8%, N = 912 713) prescriptions (mean 0.36 (SD 0.7) (95% CI, 0.36 to 0.37)). Women encountered 63.5% of all DDIs. Effect sizes for the association between DDIs and age group (Cramér's V = 0.06), and gender (Cramér's V = 0.05) was negligible. There was no difference between men and women regarding the mean number of DDIs identified per prescription (Cohen's d = 0.10). The number of medicine per prescription (ƒ2 = 0.51) was the biggest predictor of the DDIs. The most frequent interacting drug combinations were between central nervous system medicines (30.6%). Our study is the first to report the prevalence of potentially serious DDIs among an elderly population in the South African private health sector utilising the Mimica Matanović/Vlahović-Palčevski DDI protocol. Overall, we identified DDIs in approximately 26% of the prescriptions in our study. Age and gender were not found to be predictors of potentially serious DDIs.

Cost-savings accruable to removing value added tax from antiretrovirals in the South African private health sector

BackgroundDespite the important and essential role that medicines play in any society, all medicines, including those identified as essential, are uniformly subjected to 14% value added tax (VAT), regardless of their therapeutic value in the private healthcare sector of South Africa. The aim of this article is to demonstrate the potential cost-saving attained from the removal of VAT from the private sector pricing of essential medicines, using antiretroviral treatment as an example. MethodsAn empirical analysis was undertaken to illustrate the potential cost-saving achieved by removing VAT from the Single Exit Price and the dispensing fee of essential medicines. This outcome was demonstrated by applying the methodology to an adult fixed dose combination 1st line antiretroviral regimen as well as to a group of 3rd line antiretroviral medicines. ResultsThe potential saving for the lowest priced generic and originator 1st line antiviral regimen accrued to ZAR 693.84 and ZAR 1085.04 over a year respectively. Regarding the 3rd line antiretroviral drugs, results yielded an annual saving of ZAR 1678.68 (darunavir), ZAR 5741.04 (maraviroc) and ZAR 159.48 (rilpivirine). ConclusionsLobbying for the removal of VAT from the supply chain of medicines should be intensified. Policy development to monitor and recover lost government revenue through the removal of taxes should be explored.

Anti-epileptic prescribing patterns in the South African private health sector (2008–2013)

Background: Little is known about longitudinal prescribing practices for anti-epileptic drugs (AEDs) in South Africa. The prescribing patterns and associated direct medicine costs of AEDs in the private health sector were investigated, using claims data from January 1, 2008 to December 31, 2013.Methods: The annual prevalence of prescriptions, AEDs and AED generics per patient with epilepsy (ICD-10 code G40) was determined. Cost analyses conducted included the calculation of the total direct cost of AEDs (medical scheme contribution, patient co-payment, and single exit price (SEP)), and the average cost per AED per year.Results: Prevalence of patients claiming anti-epileptics ranged between 0.87% and 0.91% from 2008 to 2013. AED prescriptions/patient ranged from 11.76 (95% CI, 11.56–11.95)] in 2008 to 11.90 (95% CI, 11.71–12.09) in 2013. Patients aged 40–65 years had the highest number of AED prescriptions/year. Valproate was most prescribed, followed by lamotrigine and carbamazepine. Average cost per AED increased from R237.12 (95% CI, 233.58–240.65) in 2008 to R522.32 (95% CI, 515.24–529.41) in 2013, while the average patient co-payments increased from R27.76 (95% CI, 26.63–28.89) to R264.32 (95% CI, 260.61–268.03). Prescribing of generics increased by 12.84%.Conclusions: Generic prescribing increased over time; however, patient co-payments increased dramatically.

Prevalence of chronic diseases in private healthcare sector of South Africa: A threat to public health

Purpose : To evaluate the prevalence of patients suffering from registered chronic disease list (CDL) conditions in a section of the South African private health sector from 2008 - 2012. Methods : This study was a retrospective analysis of the medicine claims database of a nationally (South African) representative Pharmacy Benefit Management (PBM) company data between 2008 and 2012. Statistical analysis was used to analyse the data. Descriptive analysis was performed to calculate the prevalence of CDL conditions for the entire population, and stratified by age and gender. However, MIXED linear modelling was used to determine changes in the average number of CDL conditions per patient, adjusted for age and gender from 2008 - 2012. Results : An increase of 0.20 in chronic diseases was observed from 2008 - 2012 in patients having any CDL condition, with an average of 1.57 (1.57 - 1.58, 95 % CI) co-morbid CDL conditions in 2008 and 1.77 (1.77 - 1.78, 95 % CI) in 2012. This increase in average number of CDL conditions per patient between 2008 and 2012 was statistically significant (p < 0.05), but with no large practical significance (d < 0.8). Conclusion : Prevalence of patients with CDL conditions along with risk of co-morbidity has been increasing with time in the private health sector of South Africa. Risk of increased co-morbidity with age and among different genders was prevalent. Keywords : Chronic disease list, Prevalence, Private health sector, Co-morbidity

Anti-epileptic prescribing patterns in the South African private health sector (2008–2013)

Background: Little is known about longitudinal prescribing practices for anti-epileptic drugs (AEDs) in South Africa. The prescribing patterns and associated direct medicine costs of AEDs in the pr...

Human papillomavirus (HPV) vaccination of adolescents in the South African private health sector: Lessons from the HPV demonstration project in KwaZulu-Natal.

In South Africa (SA), >4,000 women die annually of cervical cancer, a disease caused by the human papillomavirus (HPV). Infections caused by certain genotypes of HPV increase the risk of cervical cancer. HIV-infected women in particular are more likely to have persistent HPV infection, with higher-risk genotypes. In SA, two vaccines (HPV quadrivalent (types 6, 11, 16, and 18) vaccine, recombinant (Gardasil) and HPV bivalent (types 16 and 18) vaccine, recombinant (Cervarix)) are currently registered for the prevention of HPV-related disease. In the past, there have been significant challenges to achieving high coverage and uptake of vaccination–contributory factors include cost and lack of awareness. An HPV demonstration project among schoolgirls in rural KwaZulu-Natal showed that high vaccine uptake is achievable. In 2014, the National Department of Health launched the national HPV vaccination programme among female learners attending public schools. Awareness of HPV vaccination among healthcare providers, education of parents, teachers and learners, and avoidance of missed opportunities for vaccination are vital to the success of the programme. Primary healthcare practitioners may play an important role in cervical cancer prevention by identifying and offering vaccination to girls who miss the opportunity to be vaccinated at school. HPV vaccination should be considered as one arm of a comprehensive programme of cervical cancer prevention and control.

Work satisfaction of medical doctors in the South African private health sector

This paper aims to determine the extent of work satisfaction among general practitioners and to examine the variables influencing the different aspects of their work satisfaction. This was a cross-sectional survey of general practitioners in the private sector, conducted throughout South Africa, using a self-administered questionnaire. Univariate statistical models were used to evaluate levels of satisfaction with various facets of work, while inferences about the effect of several independent variables on the work satisfaction facets were drawn from multiple regression models using a stepwise regression procedure. Doctors were satisfied with the social and personal aspects of their work and dissatisfied with the practice environment pressures and work setting issues. Overall, doctors were dissatisfied with their work and their careers. Being female, working in large groups, having been in practice for 20 years or more, having a high proportion of insured patients and being incentivised to conserve resources were significant predictors of lower overall satisfaction. Clinical freedom, positive perceptions of managed care strategies, remuneration on a fee-for-service basis and working in small groups were predictors of greater overall satisfaction. The paper shows that, although doctors were generally dissatisfied, there are opportunities for enhancing work satisfaction and care provision if policymakers, administrators and health care managers work in collaboration with doctors to provide the specific working conditions that health professionals desire.

Physician perceptions of managed care strategies, and impact of these on their clinical performance, in the South African private health sector

Managed care strategies have been introduced into the South African private health sector a decade ago to help reduce medical costs in this sector. A cross-sectional survey using a self-administered questionnaire was conducted among primary care physicians in this sector to access their perceptions of these strategies and to analyse impact of these on their clinical behaviour. The results indicate that although insurers were not using these strategies extensively, doctors generally perceived them negatively. It was, however, pleasing to note that the newer generation of doctors, appear to be more accepting of this new philosophy of health-care delivery.

Inadequate treatment for sexually transmitted diseases in the South African private health sector.

Correct management of sexually transmitted diseases (STDs) is important for their control, and to reduce HIV transmission. Guidelines on syndromic management of STDs were introduced by the provincial Department of Health in KwaZulu/Natal (KZN) in South Africa in 1995. The drug treatment provided for STDs by the 11 private general practitioners in one rural district was assessed and compared with provincial guidelines. Information was gathered through semistructured interviews which asked the 11 doctors, who all dispense prescribed drugs as part of the consultation fee, how they would treat 3 hypothetical cases of STD syndromes. In all 33 prescriptions, the treatment did not correspond exactly with provincial recommendations and only 3 (9%) were adequate. All other prescriptions were inadequate because dose or duration was incorrect in 6 (18%), or because incorrect drugs were prescribed in 24 (73%) of cases. Eight of the 11 doctors did not provide adequate treatment for any of their cases. A continuing medical education programme for the doctors and their staff was devised to improve the STD treatment in the private sector in this South African district.