A tale of two systems—Nurses practice environment, well being, perceived quality of care and patient safety in private and public hospitals in South Africa: A questionnaire survey

Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves. We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used. Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.

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A 'snip' in time: what is the best age to circumcise?

Here we review the international evidence for benefits and risks of infant male circumcision (MC) and use this to develop an evidence-based policy statement for a developed nation setting, focusing on Australia. Evidence from good quality studies that include meta-analyses and randomized controlled trials showed that MC provides strong protection against: urinary tract infections and, in infancy, renal parenchymal disease; phimosis; paraphimosis; balanoposthitis; foreskin tearing; some heterosexually transmitted infections including HPV, HSV-2, trichomonas, HIV, and genital ulcer disease; thrush; inferior hygiene; penile cancer and possibly prostate cancer. In women, circumcision of the male partner protects against HPV, HSV-2, cervical cancer, bacterial vaginosis, and possibly Chlamydia. MC has no adverse effect on sexual function, sensitivity, penile sensation or satisfaction and may enhance the male sexual experience. Adverse effects are uncommon (<1%), and virtually all are minor and easily treated. For maximum benefits, safety, convenience and cost savings, MC should be performed in infancy and with local anesthesia. A risk-benefit analysis shows benefits exceed risks by a large margin. Over their lifetime up to half of uncircumcised males will suffer a medical condition as a result of retaining their foreskin. The ethics of infant MC and childhood vaccination are comparable. Our analysis finds MC is beneficial, safe and cost-effective, and should optimally be performed in infancy. In the interests of public health and individual wellbeing, adequate parental education, and steps to facilitate access and affordability should be encouraged in developed countries.

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Infant male circumcision: An evidence-based policy statement

Background: The time of labor, birth and the first days of life are the most vulnerable period for mothers and children. Despite significant global advocacy, there is insufficient understanding of the investment required to save additional lives. In particular, stillbirths have been neglected. Over 20 000 stillbirths are recorded annually in South Africa, many of which could be averted. This analysis examines available South Africa specific stillbirth data and evaluates the impact and cost-effectiveness of 13 interventions acknowledged to prevent stillbirths and maternal and newborn mortality. Methods: Multiple data sources were reviewed to evaluate changes in stillbirth rates since 2000. The intervention analysis used the Lives Saved tool (LiST) and the Family Planning module (FamPlan) in Spectrum. LiST was used to determine the number of stillbirths and maternal and neonatal deaths that could be averted by scaling up the interventions to full coverage (99%) in 2030. The impact of family planning was assessed by increasing FamPlan’s default 70% coverage of modern contraception to 75% and 80% coverage. Total and incremental costs were determined in the LiST costing module. Cost-effectiveness measured incremental cost effectiveness ratios per potential life years gained. Results: Significant variability exists in national stillbirth data. Using the international stillbirth definition, the SBR was 17.6 per 1 000 births in 2013. Full coverage of the 13 interventions in 2030 could reduce the SBR by 30% to 12.4 per 1 000 births, leading to an MMR of 132 per 100 000 and an NMR of 7 per 1 000 live births. Increased family planning coverage reduces the number of deaths significantly. The full intervention package, with 80% family planning coverage in 2030, would require US$420 million (US$7.8 per capita) annually, which is less than baseline costs of US$550 million (US$10.2 per capita). All interventions were highly cost-effective. Conclusion: This is the first analysis in South Africa to assess the impact of scaling up interventions to avert stillbirths. Improved coverage of 13 interventions that are already recommended could significantly impact the rates of stillbirth and maternal and neonatal mortality. Family planning should also be prioritized to reduce mortality and overall costs.

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Triple return on investment: the cost and impact of 13 interventions that could prevent stillbirths and save the lives of mothers and babies in South Africa

The book reflects academically on important and relevant ethical fields from a multidimensional South African context. The book challenges conventional borders from different ethical, theological, philosophical, economic and cultural perspectives with insight and expertise and seeks to add academic-ethical value, locally and globally, with its different points of departure deeply embedded in justice. From a mainly qualitative methodological perspective, this scholarly book demonstrates that ethics requires analytical thinking and critical people who, in an existentially and emancipatory way, can help make the world a more just, decent and humane place in which to live. The authors, who represent different academic and cultural backgrounds, present in their respective chapters their research systematically, intersectionally and constructivistically, based on profound theoretical analysis and reasoning. This epistemology results in an act of knowing that actively gives meaning and order to the reality to which it is responding. By doing this, they point out that people are in an ongoing process of becoming more human – allowing ourselves and our fellow human beings to flourish and to reach fuller potential through justice-based ethical reflection and action.

Justice-based ethics: Challenging South African perspectives

The health policy and legislation arena has been dominated in 2015/2016 by the release, after much delay, of the White Paper on National Health Insurance (NHI). Although a White Paper is expected to provide finality on a policy in a manner which is ready for implementation, including the development of any necessary legislation, the NHI document leaves many questions unanswered. The need for major changes to existing legislation is signalled in the White Paper, but few details are provided on exactly how those changes might be made. In addition to changes to the National Health Act and the Medical Schemes Act, and perhaps even the Constitution, the possibility of a new NHI Act is also flighted. Two small steps, in the form of drafts Bills to amend the National Health Laboratory Service Act and to create a new National Public Health Institute of South Africa, have been taken. However, neither Bill has yet been tabled in Parliament.
The Medicines and Related Substances Amendment Acts of 2008 and 2015 will need careful promulgation, once the necessary secondary (regulations) and tertiary (guidelines) legislation have been developed. The new South African Health Products Regulatory Authority is not expected to come into operation before 2017, and will have to face not only the backlog in registration applications for medicines that is the legacy of the Medicines Control Council, but also complete and entrench the effective regulation of complementary medicines and medical devices.
While there have been strident calls for a fundamental redesign of the Health Professions Council of South Africa in order to create an independent, self-regulatory council for the medical and dental professions, it is unclear whether these calls will be heeded.
The Medical Innovation Bill, one of the few Private Member's Bills to be tabled, still languishes in Parliament.

Health policy and legislation

South African health review 2018

Correspondence to Dr Katrina Perehudoff; katrina. perehudoff@ gmail. com © Author(s) (or their employer(s)) 2022. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. Significant shortcomings in the global response to COVID19 have revealed a longstanding reality: the current international health and intellectual property (IP) laws and practices fail to deliver equitable access to medical countermeasures (ie, vaccines, therapeutics, diagnostics and personal protective equipment) for global health crises. Since 2020, governments worldwide have spent US$5.6 billion on COVID19 research and development (R&D) and US$45 billion on advanced purchase agreements. Yet, these funding agreements have not enabled the transfer of manufacturing knowhow to scale up vaccine production and make access more equal. As a result, large parts of the world were left unprotected from the virus, allowing the rise of new variants and prolonging the pandemic for everyone. On 1 December 2021, the 194 Member States of the World Health Organization (WHO) agreed to begin negotiations towards an international instrument that would better position the world to prevent, respond and prepare for future pandemics. (This instrument is often called a ‘pandemic treaty’.) These Member States recognised that a ‘(lack of) equity is at the core of the breakdown in the current system’ while acknowledging that the challenges in ensuring ‘universal and equitable access and distribution’ of medical countermeasures could be ‘meaningfully addressed under the umbrella of a potential new instrument’. A pandemic treaty presents an opportunity to address these challenges and craft a better system, based on solidarity, for the global governance of medical countermeasures. This commentary identifies key aspects of a Summary box

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A pandemic treaty for equitable global access to medical countermeasures: seven recommendations for sharing intellectual property, know-how and technology

South Africa is renowned for having a progressive Constitution with strong protection of human rights, including protection for persons using the public health system. While significant recent discourse and jurisprudence have focused on the rights of patients, the situation and rights of providers of health care services have not been adequately ventilated. This paper attempts to foreground the position of the human resources personnel located at the centre of the roll-out of the government's ambitious programme of anti-retroviral (ARV) therapy. The HIV/AIDS epidemic represents a major public health crisis in our country and, inasmuch as various critical policies and programmes have been devised in response, the key to a successful outcome lies in the hands of the health care professionals tasked with implementing such strategies. Often pilloried by the public, our health care workers (HCWs) face an almost Herculean task of turning the tide on the epidemic. Unless the rights of HCWs are recognised and their needs adequately addressed, the best laid plans of government will be at risk. This contribution attempts to identify and analyse the critical challenges confronting HCWs at the coalface of the HIV/AIDS treatment programme, in particular the extent to which their own rights are under threat, and offers recommendations to remedy the situation in order to ensure the successful realisation of the ARV rollout. KEYWORDS: Health care, anti-retroviral therapy, HIV/AIDS

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Challenges confronting health care workers in government's ARV rollout: rights and responsibilities

What happens when the assertion of intellectual property rights by their holders impacts on the human rights of consumers, in particular, their right to access health care and health products such as medicines? Proponents of access to medicines as a human right reference the soft law of human rights and the broad ethical frameworks within which human rights understandings are situated but, paradoxically, the pharmaceutical companies that hold proprietary interests in medicines also claim human rights to their medical discoveries. They argue that the ecology of research and development on medicines is inextricably linked to the possession of exclusive rights in the form of patent and data protections. The proprietary interests of pharmaceutical companies are stringently pursued and enforced by global powers via their trade policy and otherwise. Thus, this article argues that human rights must trump those proprietary rights, for a number of reasons, and seeks to introduce a social justice perspective on the human rights/intellectual property debate. It begins by reviewing the competing paradigms of the right to health versus proprietary intellectual property rights, showing how the human rights regime has achieved superiority in theory, but inferiority in practice. It proceeds to delineate the context in which essential medicines have increasingly become endangered global public goods. This is primarily because of strong intellectual property protections afforded to pharmaceutical companies with the advent of the TRIPS Agreement, TRIPS-plus bilateral and regional trade agreements between the USA and the European Union and developing countries, and other measures designed to broaden, strengthen and lengthen intellectual property protections worldwide. The article then explores the potential for lobbying, advocacy, law reform measures and activism in achieving the objective of 'access to medicines for all', and demonstrates the extent to which human rights advocacy programmes can contribute to doing so through the delivery of rights-based education and training to targeted audiences.

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Yousuf A. Vawda

Papers

Health policy and legislation

South African health review 2018

A pandemic treaty for equitable global access to medical countermeasures: seven recommendations for sharing intellectual property, know-how and technology

Challenges confronting health care workers in government's ARV rollout: rights and responsibilities

Achieving social justice in the human rights/intellectual property debate: Realising the goal of access to medicines