South African Medical Journal - November 2023 Vol 113 No 11

Introduction

Special series on the District Health System

The District Health System (DHS) is the building block of South Africa (SA)’s national health system. The DHS was formally established through the National Health Act No. 61 of 2003 as the most decentralised public governance structure for the achievement of an equitable health system based on primary healthcare. In the decade after 1994, the DHS was a central focus of national policy and system development, but following the advent of the Millennium Development Goals and the rise of HIV, attention shifted to disease priorities and programmes – notably HIV, tuberculosis and maternal and child health. This selective focus has resulted in some successes. Yet it has also, probably unavoidably, left a legacy of fragmented interventions in multiple, poorly co-ordinated programmes, little decentralised authority and insufficient capacity in the DHS. Subdistrict governance and leadership remain underdeveloped, with significant consequences for service delivery.

Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa

The District Health System (DHS) was formally established in the National Health Act No. 61 of 2003 as the building block of South Africa (SA)’s national health system. This policy followed the World Health Organization (WHO)’s recommendation of the DHS as the most decentralised structure of governance for the achievement of an equitable health system based on primary healthcare (PHC). Geographically and population-wise, the subdistrict in SA most closely resembles the WHO’s ideal of a health district, that is, of sufficient scale and scope to impact on health while retaining the ability to respond to local needs and co-ordinate actors. With the advent of National Health Insurance (NHI) reforms, and post-COVID 19 pandemic recovery plans, the subdistrict is (re-)emerging as an important unit of governance and service delivery co-ordination in SA. In the NHI Bill (2019), the ‘contracting unit for primary healthcare’ is ‘comprised of a district hospital, clinics or community health centres and ward-based outreach teams and private providers organised in horizontal networks within a specified geographical subdistrict area’.

LSD and psilocybin for chronic nociplastic pain: A narrative review of the literature supporting the use of classic psychedelic agents in chronic pain

Chronic pain is one of the leading global burdens of disease. It impacts an estimated 20% of the global population, and often as comorbidity with other disease states. The International Association for the Study of Pain (IASP) has adopted a new definition of pain that describes the experience of pain from the perspective of the person suffering with pain. The new IASP definition from 2020 defines pain as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’. The ability to view pain through the lens of suffering allows pain to be understood as a conscious construct of the brain in response to a perceived threat. These threats may constitute a variety of internal or external factors. Viewing pain through the eyes of the person with pain incorporates the biopsychosocial aspects of the lived experience. This approach also highlights the experiential aspect of pain as part of emotional and cognitive processing that interacts with the mechanistic aspect of nociceptive pain physiology on a receptor pathway level. When people suffer from chronic pain these factors become compounded.

Trisomy 21 screening with αlpha software and the Fetal Medicine Foundation algorithm

Prenatal screening for trisomy 21 has become an integral part of antenatal care. The first screening method for trisomy 21 was an amniocentesis for fetal karyotyping. This was offered to pregnant women of advanced maternal age. Subsequently, biochemical tests were developed that could be done in the first or second trimester (biochemical screening) to identify pregnancies at high risk of fetal trisomy 21. Ultrasound markers on their own (ultrasound screening), and in combination with biochemical tests (combined screening), were then shown to improve the accuracy of screening. Screening with first trimester ultrasound markers (including the nuchal translucency thickness) is more accurate than second trimester ultrasound markers.Non-invasive prenatal testing (NIPT) is the most recent development. NIPT measures the free fetal DNA circulating in maternal blood to detect trisomy 21. NIPT is the most sensitive and specific screening test for trisomy 21. The development of more sophisticated screening tests has increased the accuracy, but also the costs, of screening for trisomy 21.

Dyslipidaemia in patients with chronic kidney disease – a neglected cardiovascular risk factor

Atherosclerotic cardiovascular disease (ASCVD), including cerebrovascular disease, coronary artery disease, peripheral vascular disease and aortic aneurysm, contributes significantly to global morbidity and mortality, and is the leading cause of death in both developed and developing countries worldwide. In 2019, ASCVD was responsible for 32% (17.9 million) of deaths globally, and in South Africa (SA) in 2014, ASCVD was responsible for 215 deaths daily, second only to HIV/AIDS.

The use of emergency medical services for palliative situations in Western Cape Province, South Africa: A retrospective, descriptive analysis of patient records

The World Health Organization (WHO) has noted an increasing global demand for palliative care owing to ageing populations and consequent increasing rates of non-communicable disease. Despite this growing demand, there has been an inadequate corresponding supply of palliative care services. Estimates indicate that 56.8 million people require palliative care annually, while only 14% receive such care. This imbalance is particularly acute in low-to middle-income countries (LMICs), where up to 80% of patients requiring palliative care reside. These increased LMIC palliative needs result from greater disease burdens, resource limitations and underdeveloped palliative care provision. To correct this imbalance, integration between palliative services and other disciplines has been recommended. One such developing area of integration is between palliative care and emergency medical services (EMS). The limited existing data suggest that up to 10% of EMS call-outs may involve palliative situations and, given this intersection, palliative care should be integrated within EMS systems.

Treating drug-resistant tuberculosis in an era of shorter regimens: Insights from rural South Africa

Despite being recently overshadowed by the urgency of the novel coronavirus disease 2019 (COVID-19) pandemic, tuberculosis (TB) remains a huge global burden. Approximately one-quarter of the world’s population is infected by the bacillus Mycobacterium tuberculosis. Of these, 10.6 million cases progressed to active disease in 2021, and around 1.6 million people died. In 2019, TB was still the leading global cause of death by a single infectious organism. Drug-resistant TB (DR-TB) forms a significant proportion of this burden, comprising around 4% of incident cases. In comparison to drug-susceptible strains (DS-TB), treatment up until recently has been prolonged (9 -24 months), is more expensive, and has less favourable outcomes. As one of seven countries who shoulder two-thirds of the global burden, South Africa (SA) carries a disproportionately large share of global DR-TB. The local DR-TB landscape included 13 005 patients diagnosed, and 8 743 (67%) initiated on treatment in 2019, and a number of focused interventions have recently been introduced in response. However, set in the most unequal country in the world (based on Gini coefficients), the contours of this landscape require careful mapping to understand the disaggregated effects of these interventions. A rural facet is, as far as the authors of this study are aware, yet to be well described.

Biliary atresia: The profile, management and outcome of patients treated at a tertiary hospital in central South Africa

Biliary atresia (BA) is an idiopathic progressive, fibro-obliterative cholangiopathy affecting both the intra- and extrahepatic bile ducts and occurring during the perinatal period. Without intervention, the disease rapidly progresses to hepatic fibrosis and cirrhosis, with end-stage liver failure and death within the first 3 years of life. Although BA is a rare disease, it is the most common indication for liver transplantation (LT) in the paediatric population. The incidence of BA varies. It is common in the East, e.g. in Taiwan and Japan (1 in 5 000 - 10 000), and less prevalent in the West, e.g. in Europe and North America (1 in 15 000 - 20 000). In addition, the incidence is higher in females than in males, and in Asian and black than in white infants. The reasons for these differences remain unclear, but are probably related to genetic, environmental and cultural factors. However, the clinical presentation of BA is typical, with progressive obstructive jaundice, pale stools and dark urine. Other symptoms include vitamin K-dependent coagulopathy, ascites, portal hypertension and splenomegaly.