The demand for health care in South Africa

Supply-side solutions to health-care provision dominate the South African debate about health care. These solutions are often premised on views that health resources are too concentrated in the private health sector – which supposedly serves only a small minority of the population – and thus public sector provision needs to be expanded. We argue that this rests on a lack of understanding of the nature of the demand for health services. This paper estimates the determinants of the demand for health care using a multinomial logit estimation. It is found that three categories of factors influence the demand for health care. Firstly, demographic and locational variables are significant (e.g. income group, race and where the respondent lives). Secondly, the characteristics of the care provided are important (e.g. cost and distance from the respondent). Finally, the characteristics of the illness (such as its severity) are important. Overall, private health care plays a surprisingly large role in the health care decisions of all South Africans – even poor respondents reveal a clear preference for private health care, despite constraints of money and access. This dominance of the demand for private health care is likely to increase with rising incomes, or if all health services were to receive a similar subsidy (e.g. from mooted medical insurance-type schemes). On a policy level, this would indicate that greater attention should perhaps be given to health demand in considering policy alternatives.health care, South Africa

The macroeconomics of establishing a basic income grant in South Africa

This paper quantifies the effect of fiscal transfers on the trade-off between social relief and debt accumulation, and discusses the economic growth and fiscal implications of different combinations of expanded social support and funding choices. Given South Africa’s already high level of public debt, the opportunity to fund a basic income grant through higher debt is limited. Using a general equilibrium model, the paper shows that extending the social relief of distress grant could be fiscally feasible provided taxes rise to fund such a programme. Implementing such a policy would, however, have a contractionary impact on the economy. A larger basic income grant (even at the level of the food poverty line) would threaten fiscal sustainability as it would require large tax increases that would crowd-out consumption and investment. The model results show that sustainably expanding social transfers requires structurally higher growth, which necessitates growth-enhancing reforms that crowd-in the private sector through, for example, relieving the energy constraint, increasing government infrastructure investment and expanding employment programmes

Nutritional behavior of cyclists during a 24-hour team relay race: a field study report

Background Information about behavior of energy intake in ultra-endurance cyclists during a 24-hour team relay race is scarce. The nutritional strategy during such an event is an important factor which athletes should plan carefully before the race. The purpose of this study was to examine and compare the nutritional intake of ultra-endurance cyclists during a 24-hour team relay race with the current nutritional guidelines for endurance events. Additionally, we analyzed the relationship among the nutritional and performance variables. Methods Using a observational design, nutritional intake of eight males (mean ± SD: 36.7 ± 4.7 years; 71.6 ± 4.9 kg; 174.6 ± 7.3 cm; BMI 23.5 ± 0.5 kg/m2) participating in a 24-hour team relay cycling race was assessed. All food and fluid intake by athletes were weighed and recorded. Additionally, distance and speed performed by each rider were also recorded. Furthermore, before to the race, all subjects carried out an incremental exercise test to determine two heart rate-VO2 regression equations which were used to estimate the energy expenditure. Results The mean ingestion of macronutrients during the event was 943 ± 245 g (13.1 ± 4.0 g/kg) of carbohydrates, 174 ± 146 g (2.4 ± 1.9 g/kg) of proteins and 107 ± 56 g (1.5 ± 0.7 g/kg) of lipids, respectively. This amount of nutrients reported an average nutrient intake of 22.8 ± 8.9 MJ which were significantly lower compared with energy expenditure 42.9 ± 6.8 MJ (P = 0.012). Average fluid consumption corresponded to 10497 ± 2654 mL. Mean caffeine ingestion was 142 ± 76 mg. Additionally, there was no relationship between the main nutritional variables (i.e. energy intake, carbohydrates, proteins, fluids and caffeine ingestion) and the main performance variables (i.e. distance and speed). Conclusions A 24-hour hours cycling competition in a team relay format elicited high energy demands which were not compensated by energy intake of the athletes despite that dietary consumption of macronutrients did not differ to the nutritional guidelines for longer events

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Benchmarking the scientific output of industrial wastewater research in Arab world by utilizing bibliometric techniques

Rapid population growth, worsening of the climate, and severity of freshwater scarcity are global challenges. In Arab world countries, where water resources are becoming increasingly scarce, the recycling of industrial wastewater could improve the efficiency of freshwater use. The benchmarking of scientific output of industrial wastewater research in the Arab world is an initiative that could support in shaping up and improving future research activities. This study assesses the scientific output of industrial wastewater research in the Arab world. A total of 2032 documents related to industrial wastewater were retrieved from 152 journals indexed in the Scopus databases; this represents 3.6 % of the global research output. The h-index of the retrieved documents was 70. The total number of citations, at the time of data analysis, was 34,296 with an average citation of 16.88 per document. Egypt, with a total publications of 655 (32.2 %), was ranked the first among the Arab countries followed by Saudi Arabia 300 (14.7 %) and Tunisia 297 (14.6 %). Egypt also had the highest h-index, assumed with Saudi Arabia, the first place in collaboration with other countries. Seven hundred fifteen (35.2 %) documents with 66 countries in Arab/non-Arab country collaborations were identified. Arab researchers collaborated mostly with researchers from France 239 (11.7 %), followed by the USA 127 (6.2 %). The top active journal was Desalination 126 (6.2 %), and the most productive institution was the National Research Center, Egypt 169 (8.3 %), followed by the King Abdul-Aziz University, Saudi Arabia 75 (3.7 %). Environmental Science was the most prevalent field of interest 930 (45.8 %). Despite the promising indicators, there is a need to close the gap in research between the Arab world and the other nations. Optimizing the investments and developing regional experiences are key factors to promote the scientific research

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

The demand for labour in South Africa : a theoretical and empirical approach

Thesis (MComm)--Stellenbosch University, 2004.ENGLISH ABSTRACT: Nearly five million South Africans were unemployed in 2002 and creating employment opportunities is a difficult challenge. Before this issue can be tackled, however, it is critical to understand the problem. This thesis opts to contribute to this understanding by considering aspects around the demand for labour. The analysis considers a selection of the theoretical literature on the demand for labour, estimates key labour market parameters and then undertakes a number of simulations using a structural model. There are many conflicting paradigms that can be used to analyse the issue: microeconomic versus macroeconomic; neoclassical versus structuralist; theoretical versus empirical and so forth. Some of these paradigms are considered as part of the attempt to build an empirical framework that can be used to analyse the issue. The empirical results of the thesis suggest that: • Higher real wages lead to lowering of the quantity demanded of labour. The thesis estimates an economy-wide wage elasticity of employment of approximately -0,67; • Higher output stimulates the demand for labour. The single equation estimate of the employment elasticity of output is between 0,66 and 0,75, whilst the economy-wide estimate is approximately 1,1. The latter takes into account feedback effects from other macroeconomic variables, such as productivity and wages; • There is little evidence to show that the efficiency wage hypothesis holds - higher productivity leads to higher wages, but the converse is not true; • Union power increases real wages, indirectly leading to a fall in the demand for labour. This suggests that the labour market has insiders and outsiders; and • The relative price of labour is also important, with a fall in the cost of capital leading to a decrease in the demand for labour. Simulations suggest that job creation can be achieved through policies that encourage wage moderation and increase economic growth. There is also a potential role, albeit limited, for fiscal incentives such as a mooted earned income tax credit.AFRIKAANSE OPSOMMING: Byna vyf miljoen Suid-Afrikaners was werkloos in 2002 en werkskepping is 'n moeilike uitdaging. Voordat hierdie kwessie aangepak kan word, is dit egter noodsaaklik om die probleem te verstaan. Hierdie tesis dra by tot hierdie begrip deur te fokus op punte rondom die vraag na arbeid. Die ontleding kyk na 'n verskeidenheid van teoretiese literatuur oor die vraag na arbeid en identifiseer sleutel-parameters vir die arbeidsmark. Daar is soveel teenstrydige paradigmas wat gebruik kan word om die kwessie te ontleed: Mikro-ekonomies teenoor makro-ekonomies; neoklassiek teenoor strukturalisties; teoreties teenoor empiries, ensovoorts. Sommige van hierdie paradigmas word bespreek as deel van die poging om 'n empiriese raamwerk te bou wat gebruik kan word om die kwessie te ontleed. Die empiriese resultate van die tesis toon: • Hoër reële lone lei tot 'n verlaging van die hoeveelheid arbeid aangevra. Die tesis beraam die ekonomiewye loonelastisiteit van indiensneming op sowat - 0,67; • Hoër uitset stimuleer die vraag na arbeid. Die enkelvergelyking-raming van die uitset-elastisiteit van indiensneming is tussen 0,66 en 0,75, terwyl die ekonomiewye raming sowat 1,1 is. Laasgenoemde neem terugvoerinvloede van ander makro-ekonomiese veranderlikes in ag, bv. produktiwiteit en lone. • Daar is min bewyse dat die doeltreffende loon-hipotese water hou: Hoër produktiwiteit lei tot hoër lone, maar die teendeel is onwaar; • Vakbonde se mag verhoog reële lone, wat indirek lei tot 'n daling van die vraag na arbeid. Dit dui daarop dat die arbeidsmark 'n binnekring en buitestaanders het; en • Die relatiewe prys van arbeid is ook belangrik: 'n Afname van die koste van kapitaal veroorsaak 'n daling van die vraag na arbeid. Simulasies toon dat werkskepping bevorder kan word deur beleid wat loonmatiging en ekonomiese groei bevorder. Daar is ook 'n rol, alhoewel beperk, vir fiskale insentiewe, b.v. 'n loonsubsidie