BACKGROUND: South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysisOBJECTIVES: To develop and test an Ethics Framework for use in the SA context for health priority-settingMETHODS: The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approvalRESULTS: This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACsCONCLUSIONS: The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere

BACKGROUND. Vitamin D deficiency is common in intensive care unit (ICU) patients (50 - 82%) and is associated with multi-organ dysfunction. Vitamin D deficiency alters pathways of glutamine metabolism in critical illness, but the impact of vitamin D status on glutamine levels is poorly characterised.OBJECTIVES. To assess the prevalence of vitamin D deficiency and its association with organ dysfunction and glutamine levels in a South African (SA) ICU.METHODS. Records of 103 adult patients admitted to the Wits Donald Gordon Medical Centre ICU, Johannesburg, SA were retrospectively reviewed. 25-hydroxyvitamin D (25(OH)D) and glutamine levels were measured on admission. The association between admission vitamin D levels and glutamine levels, illness severity scores, organ support and outcomes was examined.RESULTS. On ICU admission, 66% (68/103) of patients were vitamin D deficient (<20 ng/mL) (95% confidence interval (CI) 56 - 75). Vitamin D deficiency was significantly associated with mechanical ventilation (40% v. 14%) (p=0.013) and a higher median sequential organ failure assessment (SOFA) score on admission (6 (interquartile range (IQR) 3 - 8) v. 4 (IQR 2 - 6)) (p=0.047) and on day 7 (5 (IQR 2 - 10) v. 2 (IQR 1 - 4)) (p=0.017). Median admission serum glutamine levels were 481 nmol/L, with 38% deficient (<420 nmol/L) (95% CI 28 - 48). Vitamin D deficiency status on admission was not significantly associated with median admission glutamine levels (p=0.66).CONCLUSIONS. Vitamin D deficiency is common in ICU patients in SA. Deficient patients were more severely ill and required more respiratory support. No significant relationship between deficiency and median glutamine levels was noted.

BACKGROUND. Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. South Africa (SA) offers a post-delivery Child Support Grant (CSG), which could encompass support during pregnancy, informed by lessons learnt from similar grants. OBJECTIVES. To review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA. METHODS. Systematic review of programmes providing cash or other support during pregnancy in low- and middle-income countries. RESULTS. Thirty-two programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support. CONCLUSIONS. Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-to-measure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health.

OBJECTIVE: To evaluate the relative effectiveness of different policies in attracting nurses to rural areas in Kenya, South Africa and Thailand using data from a discrete choice experiment (DCE). METHODS: A labelled DCE was designed to model the relative effectiveness of both financial and non-financial strategies designed to attract nurses to rural areas. Data were collected from over 300 graduating nursing students in each country. Mixed logit models were used for analysis and to predict the uptake of rural posts under different incentive combinations. FINDINGS: Nurses' preferences for different human resource policy interventions varied significantly between the three countries. In Kenya and South Africa, better educational opportunities or rural allowances would be most effective in increasing the uptake of rural posts, while in Thailand better health insurance coverage would have the greatest impact. CONCLUSION: DCEs can be designed to help policy-makers choose more effective interventions to address staff shortages in rural areas. Intervention packages tailored to local conditions are more likely to be effective than standardized global approaches.

OBJETIVO: Evaluar la eficacia relativa de diferentes políticas para atraer a las enfermeras a zonas rurales en Kenya, Sudáfrica y Tailandia utilizando los datos obtenidos mediante un modelo de elección discreta (MED). MÉTODOS: Se diseñó un MED con etiquetas para modelizar la eficacia relativa de la aplicación de estrategias financieras y no financieras para atraer a las enfermeras a las zonas rurales. Se recogieron datos de más de 300 estudiantes de enfermería al término de la carrera en cada país, y se aplicaron modelos logit mixtos para analizar y predecir la ocupación de los puestos rurales en respuesta a distintas combinaciones de incentivos. RESULTADOS: Las preferencias de las enfermeras ante diferentes intervenciones en materia de recursos humanos difirieron significativamente entre los tres países. En Kenya y Sudáfrica, unas mejores oportunidades educativas o la instauración de subsidios rurales serían la fórmula más eficaz para aumentar la ocupación de los puestos rurales, mientras que en Tailandia se conseguiría el máximo impacto ampliando la cobertura del seguro de enfermedad. CONCLUSIÓN: Es posible diseñar MED que ayuden a las autoridades a elegir las intervenciones más eficaces para hacer frente a la escasez de personal en las zonas rurales. Los paquetes de intervenciones adaptados a las condiciones locales tienen más probabilidades de ser eficaces que los enfoques mundiales normalizados.

OBJECTIF: Comparer l'efficacité de différentes politiques visant à attirer le personnel infirmier dans les zones rurales au Kenya, en Afrique du Sud et en Thaïlande, en utilisant les données d'une expérience à choix discrets. MÉTHODES: Une expérience à choix discrets a été conçue pour modéliser l'efficacité d'incitations financières et non financières visant à attirer le personnel infirmier dans les zones rurales. Dans chaque pays, des données ont été collectées auprès de 300 élèves infirmiers en fin d'études, puis analysées avec des modèles logit mixtes afin de prédire l'acceptation de postes en milieu rural en fonction de différentes combinaisons de mesures incitatives. RÉSULTATS: Les préférences du personnel infirmier pour diverses interventions de réaffectation des ressources différaient significativement entre les trois pays. Au Kenya et en Afrique du Sud, des possibilités plus intéressantes sur le plan éducatif ou des primes de ruralité seraient les incitations les plus efficaces pour améliorer le recrutement de personnel en milieu rural, tandis qu'en Thaïlande, c'est une meilleure couverture parl'assurance maladie qui aurait le plus d'impact. CONCLUSION: Des expériences à choix discrets peuvent être conçues pour aider les décideurs politiques à définir les interventions les plus efficaces pour remédier aux pénuries de personnel dans les zones rurales. Des interventions adaptées aux conditions locales seront probablement plus efficaces que des approches standardisées, définies au niveau mondial.