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Moolla A, Mdewa W, Erzse A, Hofman K, Thsehla E, Goldstein S, Kohli-Lynch C. A cost-effectiveness analysis of a South African pregnancy support grant. PLOS Glob Public Health 2024; 4:e0002781. [PMID: 38329926 PMCID: PMC10852248 DOI: 10.1371/journal.pgph.0002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/14/2024] [Indexed: 02/10/2024]
Abstract
Poverty among expectant mothers often results in sub-optimal maternal nutrition and inadequate antenatal care, with negative consequences on child health outcomes. South Africa has a child support grant that is available from birth to those in need. This study aims to determine whether a pregnancy support grant, administered through the extension of the child support grant, would be cost-effective compared to the existing child support grant alone. A cost-utility analysis was performed using a decision-tree model to predict the incremental costs (ZAR) and disability-adjusted life years (DALYs) averted by the pregnancy support grant over a 2-year time horizon. An ingredients-based approach to costing was completed from a governmental perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were performed. The intervention resulted in a cost saving of R13.8 billion ($930 million, 95% CI: ZAR3.91 billion - ZAR23.2 billion/ $1.57 billion - $264 million) and averted 59,000 DALYs (95% CI: -6,400-110,000), indicating that the intervention is highly cost-effective. The primary cost driver was low birthweight requiring neonatal intensive care, with a disaggregated incremental cost of R31,800 ($2,149) per pregnancy. Mortality contributed most significantly to the DALYs accrued in the comparator (0.68 DALYs). The intervention remained the dominant strategy in the sensitivity analyses. The pregnancy support grant is a highly cost-effective solution for supporting expecting mothers and ensuring healthy pregnancies. With its positive impact on child health outcomes, there is a clear imperative for government to implement this grant. By investing in this program, cost savings could be leveraged. The implementation of this grant should be given high priority in public health and social policies.
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Affiliation(s)
- Aisha Moolla
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Winfrida Mdewa
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Evelyn Thsehla
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ciaran Kohli-Lynch
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
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Erzse A, Desmond C, Hofman K, Barker M, Christofides NJ. Addressing unmet social needs for improved maternal and child nutrition: Qualitative insights from community-based organisations in urban South Africa. Glob Public Health 2024; 19:2329986. [PMID: 38551125 DOI: 10.1080/17441692.2024.2329986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 03/08/2024] [Indexed: 04/02/2024]
Abstract
Maternal and child malnutrition persists globally, despite existing healthcare and social protection systems. Socio-economic disadvantages contribute to high malnutrition rates, particularly in poor urban communities where many disadvantaged mothers cannot fully benefit from services. To address these disparities, a novel social needs framework has been proposed, emphasising the importance of addressing individuals' unmet needs to enhance the benefits of nutrition services. This study investigates the perceived impact of community-based organisations (CBOs) in addressing the social needs of mothers in a resource-constrained urban township in South Africa. Interviews were conducted with 18 employees from 10 CBOs working on maternal and child health, food security and social support in Soweto. Thematic analysis revealed 23 services and four pathways through which CBOs believed to address unmet social needs of beneficiaries. Services were small-scale, including food aid, learning support, and social protection assistance, available to a few in dire need. CBO services partially addressed social needs of mothers due to scale, coverage, and sustainability limitations. The South African government should reaffirm its commitment to financially supporting the non-profit sector and integrating it into government sectors to provide tailored services and resources to address diverse social needs and mitigate nutrition inequalities among mothers and children.
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Affiliation(s)
- Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Chris Desmond
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Economics and Finance, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Mary Barker
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- MRC Lifecourse Epidemiology Centre, Faculty of Medicine, University of Southampton, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Joan Christofides
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abdool Karim S, Kruger P, Mazonde N, Erzse A, Goldstein S, Hofman K. Stakeholder arguments during the adoption of a sugar sweetened beverage tax in South Africa and their influence: a content analysis. Glob Health Action 2023; 16:2152638. [PMID: 36508172 PMCID: PMC9754008 DOI: 10.1080/16549716.2022.2152638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Sugar-sweetened beverage (SSB) taxes are recognised as an effective intervention to prevent obesity. More countries are adopting SSB taxes, but the process of the adoption is politically complex. OBJECTIVE This study aimed to analyse how public participation processes influenced the South African tax. METHODS We conducted a content analysis of documents associated with the process of adopting the tax. Records were identified utilising the Parliamentary Monitoring Group database, including draft bills, meeting minutes and written submissions. The records were categorised and then inductively coded to identify themes and arguments. RESULTS We identified six cross-cutting themes advanced by stakeholders: economic considerations, impact on the vulnerable, responsiveness of an SSB tax to the problem of obesity, appropriateness of an SSB tax in South Africa, procedural concerns, and structure of the tax. Stakeholder views and arguments about the tax diverged based on their vested interests. The primary policymaker was most responsive to arguments concerning the economic impact of a tax, procedural concerns and the structure of the tax, reducing the effective rate to address industry concerns. CONCLUSION Both supportive and opposing stakeholders influenced the tax. Economic arguments had a significant impact. Arguments in South Africa broadly echoed arguments advanced in many other jurisdictions.
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Affiliation(s)
- Safura Abdool Karim
- SAMRC Wits Centre for Health Economics and Decision Science (PRICELESS SA), Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa,College of Law and Management Studies, University of KwaZulu-Natal, Durban, South Africa,CONTACT Safura Abdool Karim Wits School of Public Health, University of Witwatersrand, York Road, Parktown North, Johannesburg2057, South Africa
| | - Petronell Kruger
- SAMRC Wits Centre for Health Economics and Decision Science (PRICELESS SA), Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Natasha Mazonde
- SAMRC Wits Centre for Health Economics and Decision Science (PRICELESS SA), Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC Wits Centre for Health Economics and Decision Science (PRICELESS SA), Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC Wits Centre for Health Economics and Decision Science (PRICELESS SA), Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC Wits Centre for Health Economics and Decision Science (PRICELESS SA), Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Verguet S, Gautam P, Ali I, Husain A, Meyer S, Burbano C, Lloyd-Evans E, Coco M, Mphangwe M, Saka A, Zelalem M, Giyose BB, Li Z, Erzse A, Hofman K, Giner C, Avallone S, Kuusipalo H, Kristjansson E, Schultz L, Bundy DAP, Angrist N. Investing in school systems: conceptualising returns on investment across the health, education and social protection sectors. BMJ Glob Health 2023; 8:e012545. [PMID: 38114237 DOI: 10.1136/bmjgh-2023-012545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/04/2023] [Indexed: 12/21/2023] Open
Abstract
Public policies often aim to improve welfare, economic injustice and reduce inequality, particularly in the social protection, labour, health and education sectors. While these policies frequently operate in silos, the education sphere can operate as a cross-sectoral link. Schools represent a unique locus, with globally hundreds of millions of children attending class every day. A high-profile policy example is school feeding, with over 400 million students worldwide receiving meals in schools. The benefits of harmonising interventions across sectors with a common delivery platform include economies of scale. Moreover, economic evaluation frameworks commonly used to assess policies rarely account for impact across sectors besides their primary intent. For example, school meals are often evaluated for their impact on nutrition, but they also have educational benefits, including increasing attendance and learning and incorporating smallholder farmers into corporate value chains. To address these gaps, we propose the introduction of a comprehensive value-for-money framework for investments toward school systems that acknowledges the return to a common delivery platform-schools-and the multisectoral returns (eg, education, health and nutrition, labour, social protection) emerging from the rollout of school-based programmes. Directly building on benefit-cost analysis methods, this framework could help identify interventions that yield the highest gains in human capital per budget expenditure, with direct implications for finance ministries. Given the detrimental impact of COVID-19 on schoolchildren and human capital, it is urgent to build back stronger and more sustainable welfare systems.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Pratibha Gautam
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Iman Ali
- Tufts University, Medford, Massachusetts, USA
| | | | | | | | | | | | | | - Albert Saka
- Ministry of Education Science and Technology, Lilongwe, Malawi
| | - Meseret Zelalem
- Maternal, Child and Adolescent Health Lead Executive Officer, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | - Boitshepo Bibi Giyose
- FAO/AUDA-NEPAD (African Union Development Agency - New Partnership for Africa's Development), Johannesburg, South Africa
| | - Zhihui Li
- Tsinghua Vanke School of Public Health, Beijing, China
| | - Agnes Erzse
- SAMRC Wits Centre for Health Economics and Decision Science PRICELESS SA, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC Wits Centre for Health Economics and Decision Science PRICELESS SA, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Céline Giner
- Organization for Economic Cooperation and Development, Paris, France
| | - Sylvie Avallone
- QualiSud, Univ Montpellier, Institut Agro, CIRAD, Avignon Université, Université de La Réunion, Montpellier, France
| | - Heli Kuusipalo
- National Institute for Health and Welfare, Helsinki, Finland
| | | | - Linda Schultz
- Research Consortium for the School Meals Coalition, London School of Hygiene and Tropical Medicine, London, UK
| | - Donald A P Bundy
- Research Consortium for the School Meals Coalition, London School of Hygiene and Tropical Medicine, London, UK
| | - Noam Angrist
- University of Oxford, Oxford, Oxfordshire, UK
- Youth Impact, Gaborone, Botswana
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Watson D, Barker M, Boua PR, Chatio S, Compaoré A, Danis M, Dalaba M, Erzse A, Hardy-Johnson P, Kehoe SH, Hofman KJ, Lawrence WT, Nonterah EA, Sorgho H, Rwafa-Ponela T, Ward KA, Tugendhaft A. What works in engaging communities? Prioritising nutrition interventions in Burkina Faso, Ghana and South Africa. PLoS One 2023; 18:e0294410. [PMID: 38091334 PMCID: PMC10718458 DOI: 10.1371/journal.pone.0294410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND "Choosing All Together" (CHAT), is a community engagement tool designed to give the public a voice in how best to allocate limited resources to improve population health. This process evaluation explored the mechanisms through which CHAT generates community engagement. METHOD The CHAT tool was adapted and implemented for use in two rural communities (Nanoro, Burkina Faso, and Navrongo, Ghana) and one urban township (Soweto, South Africa) to prioritize maternal and child nutrition interventions. Community discussions were audio-recorded, transcribed, and translated into English. Twenty-two transcripts, including six each from Navrongo and Soweto and 10 from Nanoro, were analysed thematically to generate data driven codes and themes to explain mechanisms underlying the CHAT process. The process evaluation was based on the UK MRC process evaluation guidance. RESULTS Seven themes describing the functions and outcomes of CHAT were identified. Themes described participants deliberating trade-offs, working together, agreeing on priorities, having a shared vision, and increasing their knowledge, also the skills of the facilitator, and a process of power sharing between participants and researchers. Participants came to an agreement of priorities when they had a shared vision. Trained facilitators are important to facilitate meaningful discussion between participants and those with lower levels of literacy to participate fully. CONCLUSION CHAT has been shown to be adaptable and useful in prioritising maternal and child nutrition interventions in communities in Burkina Faso, Ghana, and South Africa. Conducting CHAT in communities over a longer period and involving policy-makers would increase trust, mutual respect and develop partnerships.
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Affiliation(s)
- Daniella Watson
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- SAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health and Social Medicine, King’s College London, London, United Kingdom
| | - Mary Barker
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- School of Health Sciences, Faculty of Environment and Life Sciences, University of Southampton, Southampton, United Kingdom
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - P. Romuald Boua
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Samuel Chatio
- Navrongo Health Research Centre, Ghana Health Service, Accra, Ghana
| | - Adelaide Compaoré
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, United States of America
| | - Maxwell Dalaba
- Navrongo Health Research Centre, Ghana Health Service, Accra, Ghana
- Institute of Heath Research, University of Health and Allied Sciences, Ho, Ghana
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Polly Hardy-Johnson
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
| | - Sarah H. Kehoe
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
| | - Karen J. Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Wendy T. Lawrence
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- Primary Care, Population Science and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Engelbert A. Nonterah
- Navrongo Health Research Centre, Ghana Health Service, Accra, Ghana
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hermann Sorgho
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Teurai Rwafa-Ponela
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Kate A. Ward
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Aviva Tugendhaft
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Erzse A, Desmond C, Hofman K, Barker M, Christofides NJ. Qualitative exploration of the constraints on mothers' and pregnant women's ability to turn available services into nutrition benefits in a low-resource urban setting, South Africa. BMJ Open 2023; 13:e073716. [PMID: 37993159 PMCID: PMC10668265 DOI: 10.1136/bmjopen-2023-073716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/25/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVES Despite free primary healthcare services and social protection system for mothers and children, significant nutrition inequalities occur across the globe, including in South Africa. This study aimed to explore what determines mothers' ability to access and turn available services into nutrition benefits. DESIGN An exploratory qualitative study was conducted including semistructured interviews with employees from community-based organisations and focus groups with pregnant women and mothers. Discussions focused on existing services perceived as important to nutrition, differences in mothers' ability to benefit from these services, and the underlying unmet needs contributing to these disparities. Data were analysed thematically using a novel social needs framework developed for this study where social needs are defined as the requisites that can magnify (if unmet) or reduce (if met) variation in the degree to which individuals can benefit from existing services. SETTING A resource-constrained urban township, Soweto in Johannesburg. PARTICIPANTS Thirty mothers of infants (<1 year old) and 21 pregnant women attending 5 primary healthcare facilities participated in 7 focus groups, and 18 interviews were conducted with employees from 10 community-based organisations. RESULTS Mothers identified social needs related to financial planning, personal income stability, appropriate and affordable housing, access to government services, social support and affordable healthier foods. The degree to which these needs were met determined mothers' capabilities to benefit from eight services. These were clinic-based services including nutrition advice and social work support, social grants, food aid, community savings groups, poverty alleviation projects, skills training workshops, formal employment opportunities and crèches/school feeding schemes. CONCLUSION Findings demonstrate that while current social protection mechanisms and free health services are necessary, they are not sufficient to address nutrition inequalities. Women's social needs must also be met to ensure that services are accessed and used to improve the nutrition of all mothers and their children.
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Affiliation(s)
- Agnes Erzse
- SAMRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Chris Desmond
- SAMRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- School of Economics and Finance, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Mary Barker
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- MRC Lifecourse Epidemiology Centre, University of Southampton, Faculty of Medicine, Southampton, UK
| | - Nicola Joan Christofides
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Tugendhaft A, Christofides N, Stacey N, Kahn K, Erzse A, Danis M, Gold M, Hofman K. Moving towards social inclusion: Engaging rural voices in priority setting for health. Health Expect 2023; 27:e13895. [PMID: 37882224 PMCID: PMC10726206 DOI: 10.1111/hex.13895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Achieving universal health coverage (UHC) in the context of limited resources will require prioritising the most vulnerable and ensuring health policies and services are responsive to their needs. One way of addressing this is through the engagement of marginalised voices in the priority setting process. Public engagement approaches that enable group level deliberation as well as individual level preference capturing might be valuable in this regard, but there are limited examples of their practical application, and gaps in understanding their outcomes, especially with rural populations. OBJECTIVE To address this gap, we implemented a modified priority setting tool (Choosing All Together-CHAT) that enables individuals and groups to make trade-offs to demonstrate the type of health services packages that may be acceptable to a rural population. The paper presents the findings from the individual choices as compared to the group choices, as well as the differences among the individual choices using this tool. METHODS Participants worked in groups and as individuals to allocate stickers representing the available budget to different health topics and interventions using the CHAT tool. The allocations were recorded at each stage of the study. We calculated the median and interquartile range across study participants for the topic totals. To examine differences in individual choices, we performed Wilcoxon rank sum tests. RESULTS The results show that individual interests were mostly aligned with societal ones, and there were no statistically significant differences between the individual and group choices. However, there were some statistically significant differences between individual priorities based on demographic characteristics like age. DISCUSSION The study demonstrates that giving individuals greater control and agency in designing health services packages can increase their participation in the priority setting process, align individual and community priorities, and potentially enhance the legitimacy and acceptability of priority setting. Methods that enable group level deliberation and individual level priority setting may be necessary to reconcile plurality. The paper also highlights the importance of capturing the details of public engagement processes and transparently reporting on these details to ensure valuable outcomes. PUBLIC CONTRIBUTION The facilitator of the CHAT groups was a member from the community and underwent training from the research team. The fieldworkers were also from the community and were trained and paid to capture the data. The participants were all members of the rural community- the study represents their priorities.
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Affiliation(s)
- Aviva Tugendhaft
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SASchool of Public Health, Faculty of Health Sciences, University of WitwatersrandJohannesburgSouth Africa
| | - Nicola Christofides
- School of Public HealthFaculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
| | - Nicholas Stacey
- Department of Health PolicyLondon School of EconomicsLondonUK
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit—AgincourtSchool of Public Health, Faculty of Health Sciences, University of the WitwatersrandJohannesburgSouth Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SASchool of Public Health, Faculty of Health Sciences, University of WitwatersrandJohannesburgSouth Africa
| | - Marion Danis
- Department of BioethicsNational Institutes of HealthBethesdaMarylandUSA
| | - Marthe Gold
- New York Academy of MedicineNew York CityNew YorkUSA
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SASchool of Public Health, Faculty of Health Sciences, University of WitwatersrandJohannesburgSouth Africa
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Erzse A, Karim SA, Rwafa-Ponela T, Kruger P, Hofman K, Foley L, Oni T, Goldstein S. Participatory prioritisation of interventions to improve primary school food environments in Gauteng, South Africa. BMC Public Health 2023; 23:1263. [PMID: 37386466 PMCID: PMC10308686 DOI: 10.1186/s12889-023-16101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/11/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND In South Africa, overweight and obesity affect 17% of children aged 15-18. School food environments play a vital role in children's health, influencing dietary behaviours and resulting in high obesity rates. Interventions targeting schools can contribute to obesity prevention if evidence-based and context-specific. Evidence suggests that current government strategies are inadequate to ensure healthy school food environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model. METHODS A three-phased iterative study design was implemented. First, we identified contextual drivers of unhealthy school food environments through a secondary framework analysis of 26 interviews with primary school staff. Transcripts were deductively coded in MAXQDA software using the Behaviour Change Wheel and the Theoretical Domains Framework. Second, to identify evidence-based interventions, we utilised the NOURISHING framework and matched interventions to identified drivers. Third, interventions were prioritised using a Delphi survey administered to stakeholders (n = 38). Consensus for priority interventions was defined as an intervention identified as being 'somewhat' or 'very' important and feasible with a high level of agreement (quartile deviation ≤ 0.5). RESULTS We identified 31 unique contextual drivers that school staff perceived to limit or facilitate a healthy school food environment. Intervention mapping yielded 21 interventions to improve school food environments; seven were considered important and feasible. Of these, the top priority interventions were to: 1) "regulate what kinds of foods can be sold at schools", 2) "train school staff through workshops and discussions to improve school food environment", and affix 3) "compulsory, child-friendly warning labels on unhealthy foods". CONCLUSION Prioritising evidence-based, feasible and important interventions underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to tackle South Africa's childhood obesity epidemic effectively.
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Affiliation(s)
- Agnes Erzse
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
| | - Safura Abdool Karim
- University of KwaZulu-Natal, Durban, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Teurai Rwafa-Ponela
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Petronell Kruger
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Louise Foley
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Tolu Oni
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Susan Goldstein
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Erzse A, Rwafa-Ponela T, Goldstein S, Motlhatlhedi M, Watson D, Hofman KJ, Danis M, Norris SA, Ward KA, Tugendhaft A. What values drive communities' nutrition priorities in a resource constrained urban area in South Africa? BMC Public Health 2023; 23:873. [PMID: 37170249 PMCID: PMC10175056 DOI: 10.1186/s12889-023-15761-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Voices of under-resourced communities are recognised as important yet are often unheard in decisions about healthcare resource allocation. Deliberative public engagement can serve as an effective mechanism for involving communities in establishing nutrition priorities. This study sought to identify the priorities of community members of a South African township, Soweto, and describe the underlying values driving their prioritisation process, to improve nutrition in the first 1000 days of life. METHODS We engaged 54 community members (28 men and 26 women aged > 18 years) from Soweto. We conducted seven group discussions to determine how to allocate limited resources for prioritising nutrition interventions. We used a modified public engagement tool: CHAT (Choosing All Together) which presented 14 nutrition intervention options and their respective costs. Participants deliberated and collectively determined their nutritional priorities. Choices were captured quantitatively, while group discussions were audio-recorded. A thematic analysis was undertaken to identify the reasons and values associated with the selected priorities. RESULTS All groups demonstrated a preference to allocate scarce resources towards three priority interventions-school breakfast provisioning, six-months paid maternity leave, and improved food safety. All but one group selected community gardens and clubs, and five groups prioritised decreasing the price of healthy food and receiving job search assistance. Participants' allocative decisions were guided by several values implicit in their choices, such as fairness and equity, efficiency, social justice, financial resilience, relational solidarity, and human development, with a strong focus on children. Priority interventions were deemed critical to supporting children's optimal development and well-being, interrupting the intergenerational cycle of poverty and poor human development in the community. CONCLUSION Our study demonstrates how public engagement can facilitate the incorporation of community values and programmatic preferences into nutrition priority setting, enabling a responsive approach to local community needs, especially in resource constrained contexts. Findings could guide policy makers to facilitate more appropriate decisions and to improve nutrition in the first 1000 days of life.
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Affiliation(s)
- Agnes Erzse
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
| | - Teurai Rwafa-Ponela
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Molebogeng Motlhatlhedi
- SAMRC/ Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniella Watson
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Karen J Hofman
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
| | - Shane A Norris
- SAMRC/ Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Kate A Ward
- SAMRC/ Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Aviva Tugendhaft
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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10
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Gilmore AB, Fabbri A, Baum F, Bertscher A, Bondy K, Chang HJ, Demaio S, Erzse A, Freudenberg N, Friel S, Hofman KJ, Johns P, Abdool Karim S, Lacy-Nichols J, de Carvalho CMP, Marten R, McKee M, Petticrew M, Robertson L, Tangcharoensathien V, Thow AM. Defining and conceptualising the commercial determinants of health. Lancet 2023; 401:1194-1213. [PMID: 36966782 DOI: 10.1016/s0140-6736(23)00013-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 10/13/2022] [Accepted: 12/23/2022] [Indexed: 04/07/2023]
Abstract
Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.
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Affiliation(s)
| | - Alice Fabbri
- Department for Health, University of Bath, Bath, UK
| | - Fran Baum
- Stretton Health Institute, University of Adelaide, Adelaide, SA, Australia
| | | | - Krista Bondy
- Stirling Management School, University of Stirling, Stirling, UK
| | - Ha-Joon Chang
- Department of Economics, School of Oriental and African Studies University of London, London, UK
| | - Sandro Demaio
- Victorian Health Promotion Foundation, Melbourne, VIC, Australia
| | - Agnes Erzse
- South African Medical Research Council/Wits Centre for Health Economics and Decision Science, Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Nicholas Freudenberg
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Sharon Friel
- Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Acton, ACT, Australia
| | - Karen J Hofman
- South African Medical Research Council/Wits Centre for Health Economics and Decision Science, Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Paula Johns
- ACT Health Promotion, Rio de Janeiro, Brazil
| | - Safura Abdool Karim
- South African Medical Research Council/Wits Centre for Health Economics and Decision Science, Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Jennifer Lacy-Nichols
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, VIC, Australia
| | | | - Robert Marten
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark Petticrew
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Lindsay Robertson
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | | | - Anne Marie Thow
- Menzies Centre for Health Policy and Economics, University of Sydney, NSW, Australia
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11
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Erzse A, Balusik A, Kruger P, Thsehla E, Swinburn B, Hofman K. Commentary on South Africa’s syndemic of undernutrition, obesity, and climate change. S AFR J SCI 2023. [DOI: 10.17159/sajs.2023/14776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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12
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Erzse A, Karim SA, Rwafa-Ponela T, Kruger P, Hofman KJ, Foley L, Oni T, Goldstein S. Identifying priority interventions using the Behaviour Change Wheel to improve public primary school food environments in urban South Africa. Lancet Glob Health 2023; 11 Suppl 1:S19. [PMID: 36866476 DOI: 10.1016/s2214-109x(23)00102-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND In South Africa, overweight and obesity affects 13% of children and 17% of adolescents. School food environments play a vital role in dietary behaviours and resulting obesity rates. Interventions targeting schools can be effective if evidence-based and context relevant. There are substantial gaps in policy and implementation of government strategies to promote healthy nutrition environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model. METHODS A multiphased secondary analysis of individual interviews with 25 primary school staff was undertaken. First, we identified risk factors influencing school food environments using MAXQDA software; then deductively coded these using the Capability, Opportunity, Motivation-Behaviour model, which informs the Behaviour Change Wheel framework. To identify evidence-based interventions, we used the NOURISHING framework and matched interventions to risk factors. Last, interventions were prioritised through a Delphi survey, administered to stakeholders (n=38) representing health, education, food service, and not-for-profit sectors. Consensus for priority interventions was defined as an intervention being either somewhat or very important and feasible, with high level of agreement (quartile deviation ≤0·5). FINDINGS We identified 21 interventions to improve school food environments. Of these, seven were endorsed as important and feasible to enable school stakeholders', policy makers', and children's capability, motivation, and opportunity of having healthier foods within schools. Prioritised interventions targeted a range of protective and risk factors, including issues of affordability and availability of unhealthy foods within school premises. As such, top priority interventions included (1) regulations on what kinds of foods can be sold at schools; (2) compulsory, child-friendly warning labels on unhealthy foods; and (3) training of school staff through workshops and discussions to improve school nutrition environment. INTERPRETATION This is the first study to use the Behaviour Change Wheel and stakeholder engagement to identify intervention priorities to improve food environments in South African schools. Prioritisation of evidence-based, feasible, and important interventions that are underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to effectively tackle South Africa's childhood obesity epidemic. FUNDING This research was funded by the National Institute for Health Research (NIHR; grant number 16/137/34) using UK Aid from the UK Government to support global health research. AE, PK, TR-P, SG, and KJH are supported by the SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA (grant number 23108).
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Affiliation(s)
- Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | | | - Teurai Rwafa-Ponela
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Petronell Kruger
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Karen Joanne Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Louise Foley
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Tolu Oni
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Susan Goldstein
- SAMRC/Wits Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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13
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Watson D, Chatio S, Barker M, Boua PR, Compaoré A, Dalaba M, Erzse A, Godfrey K, Hofman K, Kehoe S, McGrath N, Mukoma G, Nonterah EA, Norris SA, Sorgho H, Ward KA, Hardy-Johnson P. Men’s motivations, barriers to and aspirations for their families’ health in the first 1000 days in sub-Saharan Africa: a secondary qualitative analysis. BMJ Nutr Prev Health 2023. [PMID: 37484540 PMCID: PMC10359544 DOI: 10.1136/bmjnph-2022-000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IntroductionThe first 1000 days of life are a critical period of growth and development that have lasting implications for health, cognitive, educational and economic outcomes. In sub-Saharan Africa, gender and social norms are such that many men have little engagement with maternal and child health and nutrition during pregnancy and early childhood. This study explores how men perceive their role in three sites in sub-Saharan Africa.MethodsSecondary qualitative analysis of 10 focus group discussions with 76 men in Burkina Faso, Ghana and South Africa. Data were thematically analysed to explore men’s perceptions of maternal and child health and nutrition.ResultsMen considered themselves ‘providers’ and 'advisors' within their families, particularly of finances, food and medicines. They also indicated that this advice was out of care and concern for their families’ health. There were similarities in how the men perceive their role. Differences between men living in rural and urban settings included health priorities, the advice and the manner in which it was provided. Across all settings, men wanted to be more involved with maternal and child health and nutrition. Challenges to doing so included stigma and proscribed social gender roles.ConclusionMen want a greater engagement in improving maternal and child health and nutrition but felt that their ability to do so was limited by culture-specified gender roles, which are more focused on providing for and advising their families. Involving both men and women in intervention development alongside policymakers, health professionals and researchers is needed to improve maternal and child health and nutrition.
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14
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Desmond C, Watt K, Boua PR, Moore C, Erzse A, Sorgho H, Hofman K, Roumba T, Tinto H, Ward KA. Investing in human development and building state resilience in fragile contexts: A case study of early nutrition investments in Burkina Faso. PLOS Glob Public Health 2023; 3:e0001737. [PMID: 36989221 DOI: 10.1371/journal.pgph.0001737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/27/2023] [Indexed: 03/30/2023]
Abstract
Maternal and early malnutrition have negative health and developmental impacts over the life-course. Consequently, early nutrition support can provide significant benefits into later life, provided the later life contexts allow. This study examines the limits of siloed investments in nutrition and illustrates how ignoring life-course contextual constraints limits human development benefits and exacerbates inequality, particularly in fragile contexts. This case study focuses on Burkina Faso, a country with high rates of early malnutrition and a fragile state. We modelled the impact of scaling up 10 nutrition interventions to 80% coverage for a single year cohort on stunting, nationally and sub-nationally, using the Lives Saved Tool (LiST), and the consequent impact on earnings, without and with a complementary cash-transfer in later life. The impact on earnings was modelled utilising the well-established pathway between early nutrition, years of completed schooling and, consequent adult earnings. Productivity returns were estimated as the present value of increased income over individuals' working lives, then compared to estimates of the present value of providing the cost of nutrition interventions and cash-transfers. The cost benefit ratio at the national level for scaled nutrition alone is 1:1. Sub-nationally the worst-off region yields the lowest ratio < 0.2 for every dollar spent. The combination of nutrition and cash-transfers national cost benefit is 1:12, still with regional variation but with great improvement in the poorest region. This study shows that early nutrition support alone may not be enough to address inequality and may add to state fragility. Taking a life-course perspective when priority-setting in contexts with multiple constraints on development can help to identify interventions that maximizing returns, without worsening inequality.
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Affiliation(s)
- Chris Desmond
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Kathryn Watt
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Palwendé R Boua
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
- Sydney Brenner Institute for Molecular Biosciences (SBIMB), University of Witwatersrand, Johannesburg, South Africa
| | - Candice Moore
- Department of International Relations, School of Social Sciences, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Hermann Sorgho
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Karen Hofman
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Toussaint Roumba
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Halidou Tinto
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Kate A Ward
- SAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, United Kingdom
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
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15
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Lalla-Edward ST, Mosam A, Hove J, Erzse A, Rwafa-Ponela T, Price J, Nyatela A, Nqakala S, Kahn K, Tollman S, Hofman K, Goldstein S. Essential health services delivery in South Africa during COVID-19: Community and healthcare worker perspectives. Front Public Health 2022; 10:992481. [PMID: 36568767 PMCID: PMC9773136 DOI: 10.3389/fpubh.2022.992481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
Background Between May 2020 and February 2022, South Africa's health system bore strain as it battled mitigating the coronavirus pandemic. The country's pandemic response was scrutinized. This period also brought into focus pre-existing shortcomings in the healthcare system and its governing bodies. Contextually, there is a paucity in literature on the experiences of healthcare providers and users. This study aimed to contribute information on COVID-19, with the intention of providing guidance on preparing for future infectious disease outbreaks. Methods Cross sectional exploratory qualitative methodology was employed using semi-structured interviews and focus group discussions with community members (CM) and healthcare workers (HCW) from two South African study sites: (a) rural Bushbuckridge (run by Agincourt Health and Socio-Demographic Surveillance Site) and (b), Regions D and F in Johannesburg Metropole. Results After interviewing 42 CMs and 43 HCWs, it emerged that mandated process changes while minimizing COVID-19 exposure, necessitated healthcare personnel focusing on critical care treatment at the expense of less acute ones. COVID-19 isolation protocols, extensive absenteeism and HCWs with advanced skills being perceived as more adept to treat COVID-19 patients contributed to HCWs experiencing higher workloads. Fears regarding contracting and transmitting COVID-19, suffering financial losses, and not being able to provide adequate advice to patients were recurrent themes. Dissemination of relevant information among healthcare facility personnel and communities suffered due to breakdowns in communication. Conclusion Concessions and novel strategies to avail medication to patients had to be created. Since providence was lacking, government needs to formulate health intervention strategies that embrace health literacy, alternate methods of chronic medication dispensation, improved communication across health care platforms and the use of telehealth, to circumvent the threats of possible further infectious disease outbreaks.
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Affiliation(s)
- Samanta T. Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Atiya Mosam
- South African Medical Research Council (SAMRC)/Wits Centre for Health Economics and Decision Science – PRICELESS South Africa (SA), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Hove
- Medical Research Council (MRC)/Wits Rural Public and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- South African Medical Research Council (SAMRC)/Wits Centre for Health Economics and Decision Science – PRICELESS South Africa (SA), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Teurai Rwafa-Ponela
- South African Medical Research Council (SAMRC)/Wits Centre for Health Economics and Decision Science – PRICELESS South Africa (SA), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jessica Price
- Medical Research Council (MRC)/Wits Rural Public and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Athini Nyatela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sizwe Nqakala
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- Medical Research Council (MRC)/Wits Rural Public and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen Tollman
- Medical Research Council (MRC)/Wits Rural Public and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- South African Medical Research Council (SAMRC)/Wits Centre for Health Economics and Decision Science – PRICELESS South Africa (SA), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- South African Medical Research Council (SAMRC)/Wits Centre for Health Economics and Decision Science – PRICELESS South Africa (SA), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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16
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Erzse A, Rwafa-Ponela T, Kruger P, Wayas FA, Lambert EV, Mapa-Tassou C, Ngwa E, Goldstein S, Foley L, Hofman KJ, Teguia S, Oni T, Assah F, Shung-King M, Abdool Karim S. A Mixed-Methods Participatory Intervention Design Process to Develop Intervention Options in Immediate Food and Built Environments to Support Healthy Eating and Active Living among Children and Adolescents in Cameroon and South Africa. Int J Environ Res Public Health 2022; 19:10263. [PMID: 36011902 PMCID: PMC9408217 DOI: 10.3390/ijerph191610263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/05/2022] [Accepted: 08/15/2022] [Indexed: 06/15/2023]
Abstract
Rates of obesity and related non-communicable diseases are on the rise in sub-Saharan Africa, associated with sub-optimal diet and physical inactivity. Implementing evidence-based interventions targeting determinants of unhealthy eating and physical inactivity in children and adolescents' immediate environments is critical to the fight against obesity and related non-communicable diseases. Setting priorities requires a wide range of stakeholders, methods, and context-specific data. This paper reports on a novel participatory study design to identify and address contextual drivers of unhealthy eating and physical inactivity of children and adolescents in school and in their home neighborhood food and built environments. We developed a three-phase mixed-method study in Cameroon (Yaoundé) and South Africa (Johannesburg and Cape Town) from 2020-2021. Phase one focused on identifying contextual drivers of unhealthy eating and physical inactivity in children and adolescents in each setting using secondary analysis of qualitative data. Phase two matched identified drivers to evidence-based interventions. In phase three, we worked with stakeholders using the Delphi technique to prioritize interventions based on perceived importance and feasibility. This study design provides a rigorous method to identify and prioritize interventions that are tailored to local contexts, incorporating expertise of diverse local stakeholders.
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Affiliation(s)
- Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2193, South Africa
| | - Teurai Rwafa-Ponela
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2193, South Africa
| | - Petronell Kruger
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2193, South Africa
| | - Feyisayo A. Wayas
- Research Centre for Health through Physical Activity, Lifestyle and Sport (HPALS), Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town 7935, South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Estelle Victoria Lambert
- Research Centre for Health through Physical Activity, Lifestyle and Sport (HPALS), Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town 7935, South Africa
| | - Clarisse Mapa-Tassou
- Health of Population in Transition Research Group, University of Yaoundé, Yaoundé P.O. Box 812, Cameroon
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang P.O. Box 67, Cameroon
| | - Edwin Ngwa
- Health of Population in Transition Research Group, University of Yaoundé, Yaoundé P.O. Box 812, Cameroon
| | - Susan Goldstein
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2193, South Africa
| | - Louise Foley
- MRC Epidemiology Unit, University of Cambridge, Cambridge CB2 0SL, UK
| | - Karen J. Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2193, South Africa
| | - Stephanie Teguia
- Health of Population in Transition Research Group, University of Yaoundé, Yaoundé P.O. Box 812, Cameroon
| | - Tolu Oni
- MRC Epidemiology Unit, University of Cambridge, Cambridge CB2 0SL, UK
| | - Felix Assah
- Health of Population in Transition Research Group, University of Yaoundé, Yaoundé P.O. Box 812, Cameroon
| | - Maylene Shung-King
- Health Policy and Systems Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Safura Abdool Karim
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2193, South Africa
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17
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Erzse A, Karim SA, Foley L, Hofman KJ. A realist review of voluntary actions by the food and beverage industry and implications for public health and policy in low- and middle-income countries. Nat Food 2022; 3:650-663. [PMID: 37118592 DOI: 10.1038/s43016-022-00552-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 06/14/2022] [Indexed: 04/30/2023]
Abstract
The increasing availability of unhealthy processed food products is linked to rising rates of non-communicable diseases and obesity in low- and middle-income countries. Voluntary actions (VAs) are often adopted in lieu of regulating the composition, production, marketing and sale of unhealthy commodities, but their effectiveness is unclear. This realist review examines VAs adopted by the food and beverage industry in low- and middle-income countries. We developed a conceptual framework and followed a three-stage search to identify literature and VAs and, adhering to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines, we produced a synthesized analysis of VAs. VAs, often initiated in response to governments' efforts to introduce regulations, were difficult to evaluate due to vague language and a lack of enforcement mechanisms. The review found no evidence indicating that VAs are effective in safeguarding public health. Yet their implementation has resulted in weaker responses and policy substitution, and so we suggest that VAs have the potential to negatively influence public health and policy. The United Nations should rescind their endorsement of industry involvement and mandatory measures should be favoured over VAs.
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Affiliation(s)
- Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa.
| | - Safura Abdool Karim
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
| | - Louise Foley
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Karen Joanne Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
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Rwafa-Ponela T, Price J, Nyatela A, Nqakala S, Mosam A, Erzse A, Lalla-Edward ST, Hove J, Kahn K, Tollman S, Hofman K, Goldstein S. "We Were Afraid": Mental Health Effects of the COVID-19 Pandemic in Two South African Districts. Int J Environ Res Public Health 2022; 19:ijerph19159217. [PMID: 35954573 PMCID: PMC9368439 DOI: 10.3390/ijerph19159217] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 12/14/2022]
Abstract
The impacts of pandemics are recognized to go beyond infection, physical suffering, and socio-economic disruptions. Other consequences include psychological responses. Using a mental wellbeing lens, we analyzed COVID-19-related stressors in healthcare workers (HCWs) and community members who provided and regularly accessed health services in South Africa, respectively. From February to September 2021, during the second COVID-19 wave we conducted a qualitative study in one urban and one rural district. In-depth interviews and focus group discussions were used to collect data among 43 HCWs and 51 community members purposely and conveniently selected. Most participants experienced mental health challenges regarding multiple aspects of the COVID-19 pandemic and its resulting lockdown, with a few reporting positive adjustments to change. COVID-19 impacts on mental health were consistent among both HCWs and community members in urban and rural alike. Participants' COVID-19-induced psychological responses included anxiety and fear of the unknown, perceived risk of infection, fear of hospitalization, and fear of dying. Physical effects of the pandemic on participants included COVID-19 infection and associated symptoms, possibilities of severe illness and discomfort of using personal protective equipment. These distresses were exacerbated by social repercussions related to concerns for family wellbeing and infection stigma. Lockdown regulations also intensified anxieties about financial insecurities and social isolation. At times when common coping mechanisms such as family support were inaccessible, cultural consequences related to lack of spiritual gatherings and limited funeral rites posed additional stress on participants. In preparation for future public health emergencies, recognition needs to be given to mental health support and treatment.
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Affiliation(s)
- Teurai Rwafa-Ponela
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.M.); (A.E.); (K.H.); (S.G.)
- Correspondence: ; Tel.: +27-11-717-2681
| | - Jessica Price
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (J.P.); (J.H.); (K.K.); (S.T.)
| | - Athini Nyatela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.N.); (S.N.); (S.T.L.-E.)
| | - Sizwe Nqakala
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.N.); (S.N.); (S.T.L.-E.)
| | - Atiya Mosam
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.M.); (A.E.); (K.H.); (S.G.)
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.M.); (A.E.); (K.H.); (S.G.)
| | - Samanta Tresha Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.N.); (S.N.); (S.T.L.-E.)
| | - Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (J.P.); (J.H.); (K.K.); (S.T.)
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (J.P.); (J.H.); (K.K.); (S.T.)
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (J.P.); (J.H.); (K.K.); (S.T.)
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.M.); (A.E.); (K.H.); (S.G.)
| | - Susan Goldstein
- SAMRC/Wits Centre for Health Economics and Decision Science—PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa; (A.M.); (A.E.); (K.H.); (S.G.)
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19
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Kohli-Lynch CN, Erzse A, Rayner B, Hofman KJ. Hypertension in the South African public healthcare system: a cost-of-illness and burden of disease study. BMJ Open 2022; 12:e055621. [PMID: 35193918 PMCID: PMC8867372 DOI: 10.1136/bmjopen-2021-055621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To quantify the health and economic burden of hypertension in the South African public healthcare system. SETTING All inpatient, outpatient and rehabilitative care received in the national public healthcare system. PARTICIPANTS Adults, aged ≥20 years, who receive care in the public healthcare system. OUTCOMES Worksheet-based models synthesised data from multiple sources to estimate the burden of disease, direct healthcare costs, and societal costs associated with hypertension. Results were disaggregated by sex. RESULTS Approximately 8.22 million (30.8%, 95% CI 29.5% to 32.1%) South African adults with no private health insurance have hypertension. Hypertension was estimated to cause 14 000 (95% CI 11 100 to 17 200) ischaemic heart disease events, 13 300 (95% CI 10 600 to 16 300) strokes and 6100 (95% CI 4970 to 7460) cases of chronic kidney disease annually. Rates of hypertension, hypertension-related stroke and hypertension-related chronic kidney disease were greater for women compared with men.The direct healthcare costs associated with hypertension were estimated to be ZAR 10.1 billion (95% CI 8.98 to 11.3 billion) or US$0.711 billion (95% CI 0.633 to 0.793 billion). Societal costs were estimated to be ZAR 29.4 billion (95% CI 26.0 to 33.2 billion) or US$2.08 billion (95% CI 1.83 to 2.34 billion). Direct healthcare costs were greater for women (ZAR 6.11 billion or US$0.431 billion) compared with men (ZAR 3.97 billion or US$0.280 billion). Conversely, societal costs were lower for women (ZAR 10.5 billion or US$0.743 billion) compared with men (ZAR 18.9 billion or US$1.33 billion). CONCLUSION Hypertension exerts a heavy health and economic burden on South Africa. Establishing cost-effective best practice guidelines for hypertension treatment requires further research. Such research will be essential if South Africa is to make progress in its efforts to implement universal healthcare.
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Affiliation(s)
- Ciaran N Kohli-Lynch
- SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
- Center for Health Services & Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - B Rayner
- Division of Nephrology and Hypertension, Department of Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Karen J Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
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20
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Dalaba MA, Nonterah EA, Chatio ST, Adoctor JK, Dambayi E, Nonterah EW, Azalia S, Ayi-Bisah D, Erzse A, Watson D, Hardy-Johnson P, Kehoe SH, Tugendhaft A, Ward K, Debpuur C, Oduro A, Ofosu W, Danis M, Barker M. Engaging community members in setting priorities for nutrition interventions in rural northern Ghana. PLOS Glob Public Health 2022; 2:e0000447. [PMID: 36962493 PMCID: PMC10022374 DOI: 10.1371/journal.pgph.0000447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/13/2022] [Indexed: 11/18/2022]
Abstract
This study used "Choosing All Together" (CHAT), a deliberative engagement tool to prioritise nutrition interventions and to understand reasons for intervention choices of a rural community in northern Ghana. The study took an exploratory cross-sectional design and used a mixed method approach to collect data between December 2020 and February 2021. Eleven nutrition interventions were identified through policy reviews, interaction with different stakeholders and focus group discussions with community members. These interventions were costed for a modified CHAT tool-a board-like game with interventions represented by colour coded pies and the cost of the interventions represented by sticker holes. Supported by trained facilitators, six community groups used the tool to prioritise interventions. Discussions were audio-recoded, transcribed and thematically analysed. The participants prioritised both nutrition-sensitive and nutrition-specific interventions, reflecting the extent of poverty in the study districts and the direct and immediate benefits derived from nutrition-specific interventions. The prioritised interventions involved livelihood empowerment, because they would create an enabling environment for all-year-round agricultural output, leading to improved food security and income for farmers. Another nutrition-sensitive, education-related priority intervention was male involvement in food and nutrition practices; as heads of household and main decision makers, men were believed to be in a position to optimise maternal and child nutrition. The prioritised nutrition-specific intervention was micronutrient supplementation. Despite low literacy, participants were able to use CHAT materials and work collectively to prioritize interventions. In conclusion, it is feasible to modify and use the CHAT tool in public deliberations to prioritize nutrition interventions in rural settings with low levels of literacy. These communities prioritised both nutrition-sensitive and nutrition-specific interventions. Attending to community derived nutrition priorities may improve the relevance and effectiveness of nutrition health policy, since these priorities reflect the context in which such policy is implemented.
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Affiliation(s)
- Maxwell Ayindenaba Dalaba
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Engelbert A Nonterah
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
- Julius Global Health, Julius Centre for Health Science and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Samuel T Chatio
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - James K Adoctor
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Edith Dambayi
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Esmond W Nonterah
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Stephen Azalia
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Doreen Ayi-Bisah
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Agnes Erzse
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
| | - Daniella Watson
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Polly Hardy-Johnson
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- AECC University College, Bournemouth, United Kingdom
| | - Sarah H Kehoe
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
| | - Aviva Tugendhaft
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
| | - Kate Ward
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
| | - Cornelius Debpuur
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Abraham Oduro
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Winfred Ofosu
- Upper East Regional Health Directorate, Ghana Health Service, Bolgatanga, Ghana
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, United States of America
| | - Mary Barker
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton Foundation Trust, Southampton General Hospital, Southampton, United Kingdom
- School of Health Sciences, University of Southampton, Highfield, Southampton, United Kingdom
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21
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Watson D, Kehoe SH, Erzse A, Compaoré A, Debpuur C, Nonterah EA, Sorgho H, Norris SA, Hofman KJ, Lawrence W, Newell ML, Godfrey KM, Ward KA, Barker M. Community perspectives on maternal and child health during nutrition and economic transition in sub-Saharan Africa. Public Health Nutr 2021; 24:3710-3718. [PMID: 32928324 PMCID: PMC10195324 DOI: 10.1017/s1368980020003018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 07/03/2020] [Accepted: 07/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To explore community perceptions on maternal and child nutrition issues in Sub-Saharan Africa. DESIGN Thirty focus groups with men and women from three communities facilitated by local researchers. SETTING One urban (Soweto, South Africa) and two rural settings (Navrongo, Ghana and Nanoro, Burkina Faso) at different stages of economic transition. PARTICIPANTS Two hundred thirty-seven men and women aged 18-55 years, mostly subsistence farmers in Navrongo and Nanoro and low income in Soweto. RESULTS Differences in community concerns about maternal and child health and nutrition reflected the transitional stage of the country. Community priorities revolved around poor nutrition and hunger caused by poverty, lack of economic opportunity and traditional gender roles. Men and women felt they had limited control over food and other resources. Women wanted men to take more responsibility for domestic chores, including food provision, while men wanted more involvement in their families but felt unable to provide for them. Solutions suggested focusing on ways of increasing control over economic production, family life and domestic food supplies. Rural communities sought agricultural support, while the urban community wanted regulation of the food environment. CONCLUSIONS To be acceptable and effective, interventions to improve maternal and child nutrition need to take account of communities' perceptions of their needs and address wider determinants of nutritional status and differences in access to food reflecting the stage of the country's economic transition. Findings suggest that education and knowledge are necessary but not sufficient to support improvements in women's and children's nutritional status.
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Affiliation(s)
- Daniella Watson
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, SouthamptonSO16 5YA, UK
| | - Sarah H Kehoe
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Agnes Erzse
- SAMRC Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
| | - Adélaïde Compaoré
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Cornelius Debpuur
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | | | - Hermann Sorgho
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Shane A Norris
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, SouthamptonSO16 5YA, UK
- SAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen J Hofman
- SAMRC Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa
| | - Wendy Lawrence
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Marie-Louise Newell
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, SouthamptonSO16 5YA, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Keith M Godfrey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Kate A Ward
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mary Barker
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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22
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Mukanu MM, Abdool Karim S, Hofman K, Erzse A, Thow AM. Nutrition related non-communicable diseases and sugar sweetened beverage policies: a landscape analysis in Zambia. Glob Health Action 2021; 14:1872172. [PMID: 33876714 PMCID: PMC8079008 DOI: 10.1080/16549716.2021.1872172] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background: Taxation on unhealthy products is recommended as a cost-effective intervention to address the global burden of non-communicable diseases. Taxation of sugar-sweetened beverages dis-incentivize consumption of unhealthy products. Implementation of such policies is difficult in Sub-Saharan African countries, which are targets for global corporate expansion by the sugar-sweetened beverages industry.Objective: To identify opportunities to strengthen policies relating to sugar-sweetened beverage taxation in Zambia, through: (1) understanding the policy landscape and political context in which policies for nutrition-related non-communicable diseases are being developed, particularly sugar-sweetened beverage taxation, and exploring the potential use of revenue arising from sugar-sweetened beverage taxation to support improved nutrition.Methods: We conducted a retrospective qualitative policy analysis with a review of nutrition-related non-communicable diseases policies and key informant interviews (n = 10) with policy actors. Data were coded and analyzed data using pre-constructed matrices based on the Kingdon's Policy Agenda Framework.Results: Government responses to nutrition-related non-communicable diseases were developed in an incoherent policy environment. The health sector's commitment to regulate sugar-sweetened beverages conflicted with the manufacturing sector's priorities for economic growth. Increased regulation of sugar-sweetened beverages was a priority for the health sector. Economic interests sought to grow the manufacturing sector, including the food and beverage industries. Consequently, incoherent policy objectives might have contributed to the adoption of a weakened excise tax. The general public were poorly informed about nutrition-related non-communicable diseases.Conclusions: The tension between the Government's economic and public health priorities is a barrier for strengthening fiscal measures to address nutrition-related non-communicable diseases. However, this did not prevent the introduction of a differential sugar tax on sugar-sweetened beverages. Opportunities exist to strengthen the existing taxation of sugar-sweetened beverages in Zambia. These include a more inclusive consultation process for policy formulation and comprehensive monitoring of risk factors.
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Affiliation(s)
- Mulenga M Mukanu
- Health Policy and Management Unit, University of Zambia School of Public Health, Lusaka, Zambia
| | - Safura Abdool Karim
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Anne-Marie Thow
- Menzies Centre for Health Policy, School of Public Health, The University of Sydney, Sydney, Australia
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23
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Thow AM, Erzse A, Asiki G, Ruhara CM, Ahaibwe G, Ngoma T, Amukugo HJ, Wanjohi MN, Mukanu MM, Gaogane L, Abdool Karim S, Hofman K. Study design: policy landscape analysis for sugar-sweetened beverage taxation in seven sub-Saharan African countries. Glob Health Action 2021; 14:1856469. [PMID: 33475471 PMCID: PMC7833028 DOI: 10.1080/16549716.2020.1856469] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
This paper reports on the design of a study to examine the policy landscape relevant to sugar-sweetened beverage taxation in seven sub-Saharan African countries. The study responds to the need for strong policy to address the rising burden of non-communicable diseases in the region. Sugar-sweetened beverage taxation has been widely recommended as a key component of a comprehensive policy approach to NCD prevention. However, it has proved a contentious policy intervention, with industry strongly opposing the introduction of such taxes. The aim was to identify opportunities to strengthen sugar-sweetened beverage taxation-related policy for the prevention of nutrition-related NCDs in a subset of Eastern and Southern African countries: Kenya, Tanzania, Botswana, Rwanda, Namibia, Zambia, Uganda. The study was conducted as a collaboration by researchers from nine institutions; including the seven study countries, South Africa, and Australia. The research protocol was collaboratively developed, drawing on theories of the policy process to examine the existing availability of evidence, policy context, and stakeholder interests and influence. This paper describes the development of a method for a policy landscape analysis to strengthen policies relevant to NCD prevention, and specifically sugar-sweetened beverage taxation. This takes the form of a prospective policy analysis, based on systematic documentary analysis supplemented by consultations with policy actors, that is feasible in low-resource settings. Data were collected from policy documents, government and industry reports, survey documentation, webpages, and academic literature. Consultations were conducted to verify the completeness of the policy-relevant data collection. We analysed the frames and beliefs regarding the policy ‘problems’, the existing policy context and understandings of sugar-sweetened beverage taxation as a potential policy intervention, and the political context across relevant sectors, including industry interests and influence in the policy process. This study design will provide insights to inform public health action to support sugar-sweetened beverage taxation in the region.
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Affiliation(s)
- Anne-Marie Thow
- Menzies Centre for Health Policy, School of Public Health, The University of Sydney , Sydney, Australia
| | - Agnes Erzse
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health , Johannesburg, South Africa
| | - Gershim Asiki
- School of Economics, University of Rwanda , Butare, Rwanda
| | | | - Gemma Ahaibwe
- Economic Policy Research Centre (EPRC), Makerere University , Kampala, Uganda
| | - Twalib Ngoma
- Oncology Department, Muhimbili University of Health and Allied Sciences , Dar Es Salaam, Tanzania
| | - Hans Justus Amukugo
- Community Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Milka N Wanjohi
- Health and Systems for Health Unit, African Population and Health Research Center , Nairobi, Kenya
| | - Mulenga M Mukanu
- Health Policy and Management Unit, University of Zambia School of Public Health , Lusaka, Zambia
| | - Lebogang Gaogane
- Department of Health Promotion & Education, Boitekanelo College , Gaborone, Botswana
| | - Safura Abdool Karim
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health , Johannesburg, South Africa
| | - Karen Hofman
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health , Johannesburg, South Africa
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24
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Wanjohi MN, Thow AM, Abdool Karim S, Asiki G, Erzse A, Mohamed SF, Pierre Donfouet HP, Juma PA, Hofman KJ. Nutrition-related non-communicable disease and sugar-sweetened beverage policies: a landscape analysis in Kenya. Glob Health Action 2021; 14:1902659. [PMID: 33874855 PMCID: PMC8079030 DOI: 10.1080/16549716.2021.1902659] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: The burden of undernutrition is significant in Kenya. Obesity and related non-communicable diseases are also on the increase. Government action to prevent non-communicable diseases is critical. Taxation of sugar-sweetened beverages has been identified as an effective mechanism to address nutrition-related non-communicable diseases, although Kenya is not yet committed to this. Objective: To assess the policy and stakeholder landscape relevant to nutrition related non -communicable diseases and sugar-sweetened beverage taxation in Kenya. Methods: A desk review of evidence and policies related to nutrition related non-communicable diseases and sugar-sweetened beverages was conducted. Data extraction matrices were used for analysis. Key informant interviews were conducted with 10 policy actors. Interviews were thematically analysed to identify enablers of, and barriers to, policy change towards nutrition-sweetened beverage taxation. Results: Although nutrition related non-communicable diseases are recognised as a growing problem in Kenya most food-related policies focus on undernutrition and food security, while underplaying the role of nutrition related non-communicable diseases. Policy development on communicable diseases is multi-sectoral, but implementation is biased towards curative rather than preventive services. An excise tax is charged on soft drinks, but is not specific to sugar-sweetened beverages. Government has competing roles: advocating for industrial growth, such as sugar and food processing industries to foster economic development, yet wanting to control nutrition related non-communicable diseases. There is no national consensus about the dangers posed by sugar-sweetened beverages. Conclusion: Nutrition related non-communicable diseases policies should reflect a continuum of issues, from undernutrition to food security, nutrition transition, and the escalation of nutrition related non-communicable diseases. A local advocacy case for sugar-sweetened beverage taxation has not been made. Public and policy maker education is critical to challenge the prevailing attitudes towards sugar-sweetened beverages and the western diet.
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Affiliation(s)
- Milkah N Wanjohi
- Maternal and Child Well Being Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Ann Marie Thow
- Menzies Centre for Health Policy and Director of Academic Titles, School of Public Health, The University of Sydney, Sydney, Australia
| | - Safura Abdool Karim
- SAMRC Centre for Health Economics and Decision Science Research-PRICELESS SA, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Gershim Asiki
- Maternal and Child Well Being Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Agnes Erzse
- SAMRC Centre for Health Economics and Decision Science Research-PRICELESS SA, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Shukri F Mohamed
- Health and Systems for Health Unit, African Population and Health Research Center, Nairobi, Kenya; Academic Unit of Primary Care (AUPC) and the NIHR Global Health Research Unit on Improving Health in Slums, University of Warwick, Coventry, UK.,Lown Scholars Program, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Karen J Hofman
- University of the Witwatersrand, Johannesburg, South Africa
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Thow AM, Abdool Karim S, Mukanu MM, Ahaibwe G, Wanjohi M, Gaogane L, Amukugo HJ, Ruhara CM, Ngoma T, Asiki G, Erzse A, Hofman K. The political economy of sugar-sweetened beverage taxation: an analysis from seven countries in sub-Saharan Africa. Glob Health Action 2021; 14:1909267. [PMID: 33877032 PMCID: PMC8078959 DOI: 10.1080/16549716.2021.1909267] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Non-communicable diseases are on the rise across sub-Saharan Africa. The region has become a targeted growth market for sugar-sweetened beverages, which are associated with weight gain, cardiovascular diseases and diabetes.Objective: To identify politico-economic factors relevant to nutrition-related fiscal policies, and to draw lessons regarding strategies to strengthen sugar-sweetened beverages taxation in the region and globally.Methods: We collected documentary data on policy content, stakeholders and corporate political activity from seven countries in east and southern Africa augmented by qualitative interviews in Botswana, Namibia, Kenya and Zambia, and stakeholder consultations in Rwanda, Tanzania and Uganda. Data were analysed using a political economy framework, focusing on ideas, institutions, interests and power, and a 'bricolage' approach was employed to identify strategies for future action.Results: Non-communicable diseases were recognised as a priority in all countries. Kenya, Zambia, Rwanda, Tanzania and Uganda had taxes on non-alcoholic beverages, which varied in rate and tax base, but appeared to be motivated by revenue rather than health concerns. Botswana and Namibia indicated intention to adopt sugar-sweetened beverage taxes. Health-oriented sugar-sweetened beverage taxation faced challenges from entrenched economic policy paradigms for industry-led economic growth and was actively opposed by sugar-sweetened beverage-related industries. Strategies identified to support stronger sugar-sweetened beverage taxation included shifting the economic discourse to strengthen health considerations, developing positive public opinion, forging links with the agriculture sector for shared benefit, and leadership by a central government agency.Conclusions: There are opportunities for more strategic public health engagement with the economic sector to foster strong nutrition-related fiscal policy for non-communicable disease prevention in the region.
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Affiliation(s)
- Anne Marie Thow
- Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Safura Abdool Karim
- SAMRC/Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mulenga M Mukanu
- Health Policy and Management Unit, University of Zambia School of Public Health, Lusaka, Zambia
| | - Gemma Ahaibwe
- Economic Policy Research Centre (EPRC), Makerere University, Kampala, Uganda
| | | | - Lebogang Gaogane
- Department of Health Promotion & Education, Boitekanelo College, Gaborone, Botswana
| | - Hans Justus Amukugo
- Community Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | | | - Twalib Ngoma
- Economic Social Research Foundation (ESFR), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Agnes Erzse
- SAMRC/Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Amukugo HJ, Abdool Karim S, Thow AM, Erzse A, Kruger P, Karera A, Hofman K. Barriers to, and facilitators of, the adoption of a sugar sweetened beverage tax to prevent non-communicable diseases in Namibia: a policy landscape analysis. Glob Health Action 2021; 14:1903213. [PMID: 33876708 PMCID: PMC8079035 DOI: 10.1080/16549716.2021.1903213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Nutrition-related non-communicable diseases contribute to approximately half of the premature deaths in Namibia. Westernisation and urbanisation of communities have resulted in changing dietary patterns that see people eating more refined and high sugar content foods that are a risk for nutrition-related non-communicable diseases. Sugar-sweetened beverage taxation has been found to influence consumer purchasing behaviour and to raise revenue for health-promoting activity in other low- and middle-income countries. Objectives: To analyse Namibia’s non-communicable diseases prevention policy landscape and assess the readiness of the Government to adopt sugar-sweetened beverage taxation policies for public health. Methods: Government policy documents relating to nutrition-related non-communicable diseases were analysed, utilising predetermined variables based on policy theory. Thirteen key informant interviews were conducted with stakeholders from Government, non-governmental organisations and academic institutions. Data sets were analysed utilising Kingdon’s analytical theory for agenda setting. Results: Nutrition-related non-communicable diseases are an increasing problem that requires immediate action. Diet and lifestyle are recognised as major contributors to non-communicable diseases. The Government has adopted a multisectoral approach to the control and prevention of non-communicable diseases in Namibia. A sugar-sweetened beverage tax is envisaged in policy, but there is no progress towards its enactment. At the highest level of Government, the Ministry of Finance has ruled out immediate action towards sugar-sweetened beverage taxation. There is little publicly available information about the Namibian beverages industry, but it is closely tied to the South African drinking industry and is influenced by policy action in that country. Conclusion: The Government of Namibia has taken positive steps and the policy environment is friendly towards an SSB tax. The proximity of trade and the competitive nature of the Namibian drinks industry with South Africa suggest that a regional perspective to advocacy would be of value.
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Affiliation(s)
- Hans Justus Amukugo
- Community Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Safura Abdool Karim
- University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Anne Marie Thow
- Menzies Centre for Health Policy and Director of Academic Titles, School of Public Health, the University of Sydney, Australia
| | - Agnes Erzse
- University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Petronell Kruger
- University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Abel Karera
- Allied Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Karen Hofman
- University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
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Ahaibwe G, Abdool Karim S, Thow AM, Erzse A, Hofman K. Barriers to, and facilitators of, the adoption of a sugar sweetened beverage tax to prevent non-communicable diseases in Uganda: a policy landscape analysis. Glob Health Action 2021; 14:1892307. [PMID: 33874854 PMCID: PMC8078933 DOI: 10.1080/16549716.2021.1892307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Uganda is experiencing an increase in nutrition-related non-communicable diseases. Risk factors include overconsumption of sugar-sweetened beverages. Fiscal and taxation policies aim to make the consumption of healthier foods easier. However, the adoption and implementation of fiscal policies by countries are constrained by political and economic challenges. Objective We investigated the policy and political landscape related to the prevention of nutrition-related non-communicable diseases in Uganda to identify barriers to and facilitators of the adoption of sugar-sweetened beverage taxation in Uganda. Methods A desk-based policy analysis of policies related to nutrition-related non-communicable diseases and sugar-sweetened beverage taxation was conducted. Four key informant consultations (n = 4) were conducted to verify the policy review and to gain further insight into the policy and stakeholder contexts. Analysis was framed by Kingdon’s theory of agenda setting and policy change. Results Nutrition-related non-communicable diseases were recognised as an emerging problem in Uganda. The Government has adopted a comprehensive approach to improve diets, but implementation is slow. There is limited recognition of the consumption of sugar and sugar-sweetened beverages as a contributor to the nutrition-related non-communicable disease burden in policy documents. Existing taxes on soft drinks are lower than the World Health Organization’s recommended rate of 20% and do not target sugar content. The soft drink industry has been influential in framing the taxation debate, and the Ministry of Finance previously reduced taxation of sugar-sweetened beverages. Maintaining competitiveness in a regional market is an important business strategy. However, the Ministry of Health and other public health actors in civil society have been successful (albeit marginally) in countering reductions in taxation, which are supported by industry. Conclusions An established platform for sugar-sweetened beverage taxation advocacy exists in Uganda. Compelling local research that explicitly links soft drink taxes to health goals is essential to advance sugar-sweetened beverage taxation.
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Affiliation(s)
- Gemma Ahaibwe
- Economic Policy Research Centre (EPRC), Makerere University, Makerere, Uganda
| | - Safura Abdool Karim
- SAMRC Centre for Health Economic and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Anne-Marie Thow
- Menzies Centre for Health Policy, School of Public Health, The University of Sydney, Sydney, Australia
| | - Agnes Erzse
- SAMRC Centre for Health Economic and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC Centre for Health Economic and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
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Ruhara CM, Abdool Karim S, Erzse A, Thow AM, Ntirampeba S, Hofman KJ. Strengthening prevention of nutrition-related non-communicable diseases through sugar-sweetened beverages tax in Rwanda: a policy landscape analysis. Glob Health Action 2021; 14:1883911. [PMID: 33876706 PMCID: PMC8079049 DOI: 10.1080/16549716.2021.1883911] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Food and beverages high in sugar are recognized to be among the major risk factors for nutrition-related non-communicable diseases. The growing presence of ultra-processed food producers has resulted in shifts to diets that are associated with non-communicable diseases and which include sugar-sweetened beverages. Sugar-sweetened beverage taxation presents an opportunity to prevent non-communicable diseases but it comes with challenges. Objectives: To describe the policy landscape, identify and analyse the facilitators of and barriers to strengthening taxation on sugar-sweetened beverages in Rwanda. Methods: We conducted a desk-based policy analysis to assess the facilitators of and barriers to strengthening sugary beverage taxation policy. We consulted eight stakeholders to validate the findings of the desk review. Results: Non-communicable diseases are recognized as a public health challenge in Government health and non-health policy documents. However, sugar intake is not explicitly identified as a risk factor for non-communicable diseases and existing policies do not clearly aim to reduce sugar consumption. The Rwandan Government's commitment to growing the local sugar industry and the substantial economic contribution of Rwandan beverage producers are potential barriers to fiscal policies aimed at reducing sugar consumption. However, the current 39% excise tax levied on all soft drinks could support the adoption of future sugar-sweetened beverage policies. Conclusions: The landscape for strengthening a sugar-sweetened beverage tax in Rwanda is complex. The policy environment provides both facilitators of and impediments to strengthening the existing tax. A differential tax could be introduced by leveraging on the existing excise tax and linking it to the sugar content of beverages.
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Affiliation(s)
| | - Safura Abdool Karim
- SAMRC Centre for Health Economics and Decision Science Research-PRICELESS SA, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC Centre for Health Economics and Decision Science Research-PRICELESS SA, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
| | - Anne-Marie Thow
- Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre (D17), The University of Sydney, Sydney, Australia
| | | | - Karen J Hofman
- SAMRC Centre for Health Economics and Decision Science Research-PRICELESS SA, University of the Witwatersrand, Faculty of Health Sciences, School of Public Health, Johannesburg, South Africa
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Tugendhaft A, Hofman K, Danis M, Kahn K, Erzse A, Twine R, Gold M, Christofides N. Deliberative engagement methods on health care priority-setting in a rural South African community. Health Policy Plan 2021; 36:1279-1291. [PMID: 34051093 PMCID: PMC8428615 DOI: 10.1093/heapol/czab005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 11/16/2022] Open
Abstract
Public engagement in priority-setting for health is increasingly recognized as a means to ensure more ethical, inclusive and legitimate decision-making processes, especially in the context of Universal Health Coverage where demands outweigh the available resources and difficult decisions need to be made. Deliberative approaches are often viewed as especially useful in considering social values and balancing trade-offs, however, implementation of deliberative engagement tools for priority-setting is scant, especially in low- and middle-income settings. In order to address this gap, we implemented a context-specific public deliberation tool in a rural community in South Africa to determine priorities for a health services package. Qualitative data were analysed from seven group deliberations using the engagement tool. The analysis focused on understanding the deliberative process, what the participants prioritized, the reasons for these selections and how negotiations took place within the groups. The deliberations demonstrated that the groups often considered curative services to be more important than primary prevention which related to the perceived lack of efficacy of existing health education and prevention programmes in leading to behaviour change. The groups engaged deeply with trade-offs between costly treatment options for HIV/AIDS and those for non-communicable disease. Barriers to healthcare access were considered especially important by all groups and some priorities included investing in more mobile clinics. This study demonstrates that deliberative engagement methods can be successful in helping communities balance trade-offs and in eliciting social values around health priorities. The findings from such deliberations, alongside other evidence and broader ethical considerations, have the potential to inform decision-making with regard to health policy design and implementation.
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Affiliation(s)
- Aviva Tugendhaft
- SAMRC/Wits Centre for Health Economics and Decision Science- PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science- PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit -Agincourt, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science- PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit -Agincourt, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marthe Gold
- New York Academy of Medicine, New York City, NY, USA
| | - Nicola Christofides
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Erzse A, Goldstein S, Tugendhaft A, Norris SA, Barker M, Hofman KJ. The roles of men and women in maternal and child nutrition in urban South Africa: A qualitative secondary analysis. Matern Child Nutr 2021; 17:e13161. [PMID: 33689226 PMCID: PMC8189191 DOI: 10.1111/mcn.13161] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
Industrialization and urbanization processes have challenged deeply held traditional gender norms and facilitated the emergence of modern ideologies in South Africa. This paper seeks to explore the gendered roles of family members on maternal and child nutrition and investigate indications of perceived change in related practices. A qualitative secondary analysis was conducted of data from nine focus group discussions (FGDs) held with men (n = 3) and women (n = 6) aged ≥18. Data from the FGD were coded and thematic analysis conducted. We found that elderly women seem to have a central advisory role with respect to maternal and child nutrition and that men and elderly women upheld patriarchal gender divisions of labour, which entrust mothers with the primarily responsibility for young children's nutrition. Young mothers relied on elderly women for provision of childcare and nutritious foods for children; however, they demonstrated some resistance to traditionally feminized forms of food preparation. We found that men's involvement in children's nutrition was limited, though they expressed a preference to be more involved in maternal and child nutrition and care practices. A gender transformative approach to policy development, which includes elderly women and men, has the potential to promote more gender‐equitable nutrition practices, increase young women's self‐efficacy and support them to overcome barriers that could be limiting their decision making power in achieving optimal nutrition for themselves and their children.
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Affiliation(s)
- Agnes Erzse
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Aviva Tugendhaft
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Shane A Norris
- SAMRC Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mary Barker
- MRC Lifecourse Epidemiology Unit, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Karen J Hofman
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Abdool Karim S, Erzse A, Thow AM, Amukugo HJ, Ruhara C, Ahaibwe G, Asiki G, Mukanu MM, Ngoma T, Wanjohi M, Karera A, Hofman K. The legal feasibility of adopting a sugar-sweetened beverage tax in seven sub-Saharan African countries. Glob Health Action 2021; 14:1884358. [PMID: 33876700 PMCID: PMC8078924 DOI: 10.1080/16549716.2021.1884358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 01/27/2021] [Indexed: 01/19/2023] Open
Abstract
Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems.Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia.Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws.Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures.Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention.
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Affiliation(s)
- Safura Abdool Karim
- SAMRC/Wits Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Anne-Marie Thow
- Menzies Centre for Health Policy and Director of Academic Titles, School of Public Health, The University of Sydney, Sydney, Australia
| | - Hans Justus Amukugo
- Community Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Charles Ruhara
- School of Economics, University of Rwanda, Butare, Rwanda
| | - Gemma Ahaibwe
- Economic Policy Research Centre (EPRC), Makerere University, Kampala, Uganda
| | - Gershim Asiki
- Health and Systems for Health Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Mulenga M. Mukanu
- Health Policy and Management Unit, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Twalib Ngoma
- Oncology of the Ocean Road Cancer Institute (ORCI) and Oncology Department, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Milka Wanjohi
- Health and Systems for Health Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Abel Karera
- Allied Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Erzse A, Abdool Karim S, Thow AM, Ahaibwe G, Amukugo HJ, Asiki G, Gaogane L, Mukanu MM, Ngoma T, Ruhara CM, Wanjohi MN, Hofman K. The data availability landscape in seven sub-Saharan African countries and its role in strengthening sugar-sweetened beverage taxation. Glob Health Action 2021; 14:1871189. [PMID: 33876702 PMCID: PMC8079050 DOI: 10.1080/16549716.2020.1871189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/29/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Credible data and indicators are necessary for country-specific evidence to support the design, implementation, monitoring and evaluation of sugar-sweetened beverage (SSB) taxation.Objective: A cross-country analysis was undertaken in seven Sub-Saharan African countries to describe the potential role of available data in strengthening SSB taxation. The objectives were to: document currently available data sources; report on public access; discuss strengths and limitations for use in monitoring SSB taxation; describe policy maker's data needs, and propose improvements in data collection.Methods: The study used a mixed-methods approach involving a secondary data analysis of publicly available documents, and a qualitative exploration of the data needs of policy makers' using primary data. Findings were synthesised and assessed for data strengths and weaknesses, including usability and availability. SSB taxation-related data availability was critically assessed with respect to adequacy in strengthening taxation policy on SSBs.Results: Findings showed a paucity of SSB taxation-related data in all seven countries. National survey data are inadequate regarding the intake of SSBs and household expenditure on SSBs. Fiscal data from SSB tax revenue, value added tax from SSB sales, corporate income tax from SSB companies and SSB custom duty revenues, are lacking. Accurate information on the soft drink industry is not easily accessed.Conclusion: Timely, easily understood, concise, and locally relevant evidence is needed in order to inform policy development on SSBs. The relevant data are drawn from multiple sectors. Cross- sector collaboration is therefore needed. Indicators for SSBs should be developed and included in current data collection tools to ensure monitoring and evaluation for SSB taxation.
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Affiliation(s)
- Agnes Erzse
- Faculty of Health Sciences, SAMRC/Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Safura Abdool Karim
- Faculty of Health Sciences, SAMRC/Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Anne Marie Thow
- Menzies Centre for Health Policy, School of Public Health, The University of Sydney, Sydney, Australia
| | - Gemma Ahaibwe
- Economic Policy Research Centre (EPRC), Makerere University, Makerere, Uganda
| | | | - Gershim Asiki
- African Population and Health Research Center, Health and Systems for Health Unit, Kenya
| | - Lebogang Gaogane
- Boitekanelo College, Department of Health Promotion & Education, University of Botswana, Gaborone, Botswana
| | - Mulenga M. Mukanu
- Health Policy and Management Unit, University of Zambia School of Public Health, Lusaka, Zambia
| | - Twalib Ngoma
- Economic and Social Research Foundation, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | | | - Milkah N Wanjohi
- African Population and Health Research Center, Health and Systems for Health Unit, Kenya
| | - Karen Hofman
- Faculty of Health Sciences, SAMRC/Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Johannesburg, South Africa
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Desmond C, Erzse A, Watt K, Ward K, Newell ML, Hofman K. Realising the potential human development returns to investing in early and maternal nutrition: The importance of identifying and addressing constraints over the life course. PLOS Glob Public Health 2021; 1:e0000021. [PMID: 36962074 PMCID: PMC10022083 DOI: 10.1371/journal.pgph.0000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/15/2021] [Indexed: 11/18/2022]
Abstract
The benefits of interventions which improve early nutrition are well recognised. These benefits, however, only accrue to the extent that later life circumstances allow. Consequently, in adverse contexts many of the benefits will never be realised, particularly for the most vulnerable, exacerbating inequality. Returns to investment in early nutrition could be improved if we identified contextual factors constraining their realisation and interventions to weaken these. We estimate cost and impact of scaling 10 nutrition interventions for a cohort of South African children born in 2021. We estimate associated declines in malnutrition and mortality, and improvements in years of schooling and future earnings. To examine the role of context over the life-course we estimate benefits with and without additional improvements in school quality and employment opportunities by socio-economic quintile. Scale up reduces national stunting (height for age < = -2SD) rates among children at 24 months by 3.18 percentage points, implying an increase in mean height for age z-score (HAZ) of 0.10, and 53,000 years of additional schooling. Quintile 1 (the poorest) displays the largest decline in stunting, and largest increase in mean HAZ. Estimated total cost of increasing coverage of the interventions for the cohort is US$90 million. The present value of the additional years of schooling is estimated at close to US$2 billion. Cost-benefit ratios suggest the highest return occurs in quintile 5 (1:23). Reducing inequality in school quality closes the gap between quintile 5 and the lower quintiles. If school quality and labour force participation were equal the highest returns are in quintile 1(1:31). An enabling environment is key to maximising human development returns from investing in early nutrition, and to avoid exacerbating existing inequality. Therefore, particularly for children in adverse conditions, it is essential to identify and implement complementary interventions over the life course.
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Affiliation(s)
- Chris Desmond
- Faculty of Health Sciences, SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Agnes Erzse
- Faculty of Health Sciences, SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Kathryn Watt
- Centre for Rural Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Kate Ward
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
| | - Marie-Louise Newell
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
| | - Karen Hofman
- Faculty of Health Sciences, SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of Witwatersrand School of Public Health, Johannesburg, South Africa
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Erzse A, Christofides N, Stacey N, Lebard K, Foley L, Hofman K. Availability and advertising of sugar sweetened beverages in South African public primary schools following a voluntary pledge by a major beverage company: a mixed methods study. Glob Health Action 2021; 14:1898130. [PMID: 33910480 PMCID: PMC8288764 DOI: 10.1080/16549716.2021.1898130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/28/2021] [Indexed: 10/31/2022] Open
Abstract
Background: Towards the end of the 2017 school year, a prominent beverage company in South Africa pledged to remove their sugar-sweetened beverages (SSBs) and advertisements from primary schools in order to contribute to the realization of a healthy school environment.Objectives: To assess the availability and advertising of the company's beverages in public primary schools in Gauteng province following their voluntary pledge to remove the products, and to explore perceptions of school staff regarding SSB availability in schools and processes related to the implementation of the pledge.Methods: In 2019, we conducted a representative survey of public sector primary (elementary) schools in Gauteng province, South Africa. A random sample of schools was drawn, with schools stratified by whether or not they charge fees. This was a proxy for the socioeconomic status of the locale and student body. At each school, the availability of beverages and presence of advertising or not was assessed by an observational audit tool and differences across fee status assessed by Pearson χ 2 test. Semi-structured interviews were conducted with a purposive sample of school officials. Data from the interviews were coded and thematic analysis conducted.Results: Two years following a voluntary pledge, the company's carbonated SSBs were available for sale in 54% (CI: 45-63%) of schools with tuck shops and advertised in 31% (CI: 25-39%). Qualitative interviews revealed a complex landscape of actors within schools, which, combined with indifference or resistance to the pledge, may have contributed to the continued availability of SSBs.Conclusions: Though we were unable to examine SSB availability before and after the pledge, our findings provide some preliminary evidence that voluntary pledges by commercial entities are not sufficient to remove SSBs and advertisements from schools. Mandatory regulations coupled with in-depth engagement with schools may be an avenue to pursue in the future.
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Affiliation(s)
- Agnes Erzse
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Nicola Christofides
- Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Nicholas Stacey
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Kelsey Lebard
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Louise Foley
- MRC Epidemiology Unit, University of Cambridge, UK
| | - Karen Hofman
- SAMRC/Centre for Health Economics and Decision Science, PRICELESS, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
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35
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Oni T, Assah F, Erzse A, Foley L, Govia I, Hofman KJ, Lambert EV, Micklesfield LK, Shung-King M, Smith J, Turner-Moss E, Unwin N, Wadende P, Woodcock J, Mbanya JC, Norris SA, Obonyo CO, Tulloch-Reid M, Wareham NJ. The global diet and activity research (GDAR) network: a global public health partnership to address upstream NCD risk factors in urban low and middle-income contexts. Global Health 2020; 16:100. [PMID: 33076935 PMCID: PMC7570103 DOI: 10.1186/s12992-020-00630-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 10/07/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) are the leading cause of death globally. While upstream approaches to tackle NCD risk factors of poor quality diets and physical inactivity have been trialled in high income countries (HICs), there is little evidence from low and middle-income countries (LMICs) that bear a disproportionate NCD burden. Sub-Saharan Africa and the Caribbean are therefore the focus regions for a novel global health partnership to address upstream determinants of NCDs. PARTNERSHIP The Global Diet and Activity research Network (GDAR Network) was formed in July 2017 with funding from the UK National Institute for Health Research (NIHR) Global Health Research Units and Groups Programme. We describe the GDAR Network as a case example and a potential model for research generation and capacity strengthening for others committed to addressing the upstream determinants of NCDs in LMICs. We highlight the dual equity targets of research generation and capacity strengthening in the description of the four work packages. The work packages focus on learning from the past through identifying evidence and policy gaps and priorities, understanding the present through adolescent lived experiences of healthy eating and physical activity, and co-designing future interventions with non-academic stakeholders. CONCLUSION We present five lessons learned to date from the GDAR Network activities that can benefit other global health research partnerships. We close with a summary of the GDAR Network contribution to cultivating sustainable capacity strengthening and cutting-edge policy-relevant research as a beacon to exemplify the need for such collaborative groups.
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Affiliation(s)
- Tolu Oni
- MRC Epidemiology Unit, Institute of Metabolic Sciences Building, Addenbrookes Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK.
- Research Initiative for Cities Health and Equity (RICHE), School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Felix Assah
- Health of Populations in Transition (HoPiT), Research Group, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Agnes Erzse
- SA MRC Centre for Health Economics and Decision Science (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Louise Foley
- MRC Epidemiology Unit, Institute of Metabolic Sciences Building, Addenbrookes Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Ishtar Govia
- Caribbean Institute for Health Research, The University of West Indies, Kingston, Jamaica
| | - Karen J Hofman
- SA MRC Centre for Health Economics and Decision Science (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Estelle Victoria Lambert
- Health through Physical Activity Lifestyle and Sport Research Centre, University of Cape Town, Cape Town, South Africa
| | - Lisa K Micklesfield
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), University of Witwatersrand, Johannesburg, South Africa
| | - Maylene Shung-King
- Research Initiative for Cities Health and Equity (RICHE), School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joanne Smith
- Caribbean Institute for Health Research, The University of West Indies, Kingston, Jamaica
| | - Eleanor Turner-Moss
- MRC Epidemiology Unit, Institute of Metabolic Sciences Building, Addenbrookes Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Nigel Unwin
- MRC Epidemiology Unit, Institute of Metabolic Sciences Building, Addenbrookes Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Pamela Wadende
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - James Woodcock
- MRC Epidemiology Unit, Institute of Metabolic Sciences Building, Addenbrookes Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jean Claude Mbanya
- Health of Populations in Transition (HoPiT), Research Group, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Shane A Norris
- MRC/Wits Developmental Pathways for Health Research Unit (DPHRU), University of Witwatersrand, Johannesburg, South Africa
| | - Charles O Obonyo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Marshall Tulloch-Reid
- Caribbean Institute for Health Research, The University of West Indies, Kingston, Jamaica
| | - Nicholas J Wareham
- MRC Epidemiology Unit, Institute of Metabolic Sciences Building, Addenbrookes Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
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Oni T, Micklesfield LK, Wadende P, Obonyo CO, Woodcock J, Mogo ERI, Odunitan-Wayas FA, Assah F, Tatah L, Foley L, Mapa-Tassou C, Bhagtani D, Weimann A, Mba C, Unwin N, Brugulat-Panés A, Hofman KJ, Smith J, Tulloch-Reid M, Erzse A, Shung-King M, Lambert EV, Wareham NJ. Implications of COVID-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries. Glob Health Action 2020; 13:1810415. [PMID: 32867606 PMCID: PMC7480567 DOI: 10.1080/16549716.2020.1810415] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
At the time of writing, it is unclear how the COVID-19 pandemic will play out in rapidly urbanising regions of the world. In these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the COVID-19 pandemic in these contexts. COVID-19 infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. However, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. In this current debate piece, focusing on two of the four risk factors that contribute to >80% of the NCD burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. By considering mitigation responses implemented by governments in several LMIC cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. Such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term.
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Affiliation(s)
- Tolu Oni
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK.,Research Initiative for Cities Health and Equity (RICHE), School of Public Health and Family Medicine, University of Cape Town , Cape Town, South Africa
| | - Lisa K Micklesfield
- South African MRC/Wits Developmental Pathways for Health Research Unit (DPHRU, University of Witwatersrand , Johannesburg, South Africa
| | - Pamela Wadende
- School of Education and Human Resource Development, Kisii University , Kisii, Kenya
| | - Charles O Obonyo
- Centre for Global Health Research, Kenya Medical Research Institute , Kisusmu, Kenya
| | - James Woodcock
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK
| | - Ebele R I Mogo
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK
| | - Feyisayo A Odunitan-Wayas
- Research Centre for Health through Physical Activity, Lifestyle and Sport (HPALS, University of Cape Town , Cape Town, South Africa
| | - Felix Assah
- Health of Populations in Transition (HoPiT, University of Yaoundé , Yaounde, Cameroon
| | - Lambed Tatah
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK.,Health of Populations in Transition (HoPiT, University of Yaoundé , Yaounde, Cameroon
| | - Louise Foley
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK
| | - Clarisse Mapa-Tassou
- Health of Populations in Transition (HoPiT, University of Yaoundé , Yaounde, Cameroon
| | - Divya Bhagtani
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK
| | - Amy Weimann
- Research Initiative for Cities Health and Equity (RICHE), School of Public Health and Family Medicine, University of Cape Town , Cape Town, South Africa
| | - Camille Mba
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK.,Health of Populations in Transition (HoPiT, University of Yaoundé , Yaounde, Cameroon
| | - Nigel Unwin
- MRC Epidemiology Unit, University of Cambridge , Cambridge, UK
| | | | - Karen J Hofman
- South African MRC Centre for Health Economics and Decision Science (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of Witwatersrand , Johannesburg, South Africa
| | - Joanne Smith
- Caribbean Institute for Health Research, The University of West Indies , Kingston, Jamaica
| | - Marshall Tulloch-Reid
- Caribbean Institute for Health Research, The University of West Indies , Kingston, Jamaica
| | - Agnes Erzse
- South African MRC Centre for Health Economics and Decision Science (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of Witwatersrand , Johannesburg, South Africa
| | - Maylene Shung-King
- Research Initiative for Cities Health and Equity (RICHE), School of Public Health and Family Medicine, University of Cape Town , Cape Town, South Africa
| | - Estelle V Lambert
- Research Centre for Health through Physical Activity, Lifestyle and Sport (HPALS, University of Cape Town , Cape Town, South Africa
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Tugendhaft A, Danis M, Christofides N, Kahn K, Erzse A, Gold M, Twine R, Khosa A, Hofman K. CHAT SA: Modification of a Public Engagement Tool for Priority Setting for a South African Rural Context. Int J Health Policy Manag 2020; 11:197-209. [PMID: 32654436 PMCID: PMC9278606 DOI: 10.34172/ijhpm.2020.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 06/21/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Globally, as countries move towards universal health coverage (UHC), public participation in decisionmaking is particularly valuable to inform difficult decisions about priority setting and resource allocation. In South Africa (SA), which is moving towards UHC, public participation in decision-making is entrenched in policy documents yet practical applications are lacking. Engagement methods that are deliberative could be useful in ensuring the public participates in the priority setting process that is evidence-based, ethical, legitimate, sustainable and inclusive. Methods modified for the country context may be more relevant and effective. To prepare for such a deliberative process in SA, we aimed to modify a specific deliberative engagement tool – the CHAT (Choosing All Together) tool for use in a rural setting.
Methods: Desktop review of published literature and policy documents, as well as 3 focus groups and modified Delphi method were conducted to identify health topics/issues and related interventions appropriate for a rural setting in SA. Our approach involved a high degree of community and policy-maker/expert participation. Qualitative data were analysed thematically. Cost information was drawn from various national sources and an existing actuarial model used in previous CHAT exercises was employed to create the board.
Results: Based on the outcomes, 7 health topics/issues and related interventions specific for a rural context were identified and costed for inclusion. These include maternal, new-born and reproductive health; child health; woman and child abuse; HIV/AIDS and tuberculosis (TB); lifestyle diseases; access; and malaria. There were variations in priorities between the 3 stakeholder groups, with community-based groups emphasizing issues of access. Violence against women and children and malaria were considered important in the rural context.
Conclusion: The CHAT SA board reflects health topics/issues specific for a rural setting in SA and demonstrates some of the context-specific coverage decisions that will need to be made. Methodologies that include participatory principles are useful for the modification of engagement tools like CHAT and can be applied in different country contexts in order to ensure these tools are relevant and acceptable. This could in turn impact the success of the implementation, ultimately ensuring more effective priority setting approaches.
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Affiliation(s)
- Aviva Tugendhaft
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
| | - Nicola Christofides
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit - Agincourt, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Marthe Gold
- New York Academy of Medicine, New York City, NY, USA
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit - Agincourt, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Khosa
- MRC/Wits Rural Public Health and Health Transitions Research Unit - Agincourt, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Erzse A, Fraser H, Levitt N, Hofman K. Prioritising action on diabetes during COVID-19. S Afr Med J 2020; 110:719-720. [PMID: 32880294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 06/11/2023] Open
Affiliation(s)
- A Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science, PRICELESS, University of the Witwatersrand School of Public Health, Faculty of Health Sciences, Johannesburg, South Africa.
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Mosam A, Goldstein S, Erzse A, Tugendhaft A, Hofman K. Building trust during COVID 19: Value-driven and ethical priority-setting. S Afr Med J 2020; 110:443-444. [PMID: 32880544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/17/2020] [Indexed: 06/11/2023] Open
Affiliation(s)
- A Mosam
- PRICELESS SA: SAMRC/Wits Centre for Health Economics and Decision Science, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Erzse A, Stacey N, Chola L, Tugendhaft A, Freeman M, Hofman K. The direct medical cost of type 2 diabetes mellitus in South Africa: a cost of illness study. Glob Health Action 2019; 12:1636611. [PMID: 31282315 PMCID: PMC7012049 DOI: 10.1080/16549716.2019.1636611] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/17/2019] [Indexed: 12/04/2022] Open
Abstract
Background: Type 2 diabetes mellitus (T2DM) is known to require continuous clinical care and management that consumes significant health-care resources. These costs are not well understood, particularly in low- and middle-income countries. Objective: The aim of this study was to estimate the direct medical costs associated with T2DM in the South African public health sector and to project an estimate of the future direct costs of T2DM by 2030. Methods: A cost of illness study was conducted to estimate the direct medical costs of T2DM in South Africa in 2018 and to make projections for potential costs in 2030. Costs were estimated for diagnosis and management of T2DM, and related complications. Analyses were implemented in Microsoft Excel, with sensitivity analysis conducted on particular parameters. Results: In 2018, public sector costs of diagnosed T2DM patients were approximately ZAR 2.7 bn and ZAR 21.8 bn if both diagnosed and undiagnosed patients are considered. In real terms, the 2030 cost of all T2DM cases is estimated to be ZAR 35.1 bn. Approximately 51% of these estimated costs for 2030 are attributable to the management of T2DM, and 49% are attributable to complications. Conclusion: T2DM imposes a significant financial burden on the public healthcare system in South Africa. Treatment of all prevalent cases would incur a cost equivalent to approximately 12% of the total national health budget in 2018. With rising prevalence, direct costs will grow if current care regimes are maintained and case-finding improved. Increased financial resources are necessary in order to deliver effective services to people with T2DM.
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Affiliation(s)
- Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicholas Stacey
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lumbwe Chola
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Aviva Tugendhaft
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Melvyn Freeman
- School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science - PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Du M, Tugendhaft A, Erzse A, Hofman KJ. Sugar-Sweetened Beverage Taxes: Industry Response and Tactics. Yale J Biol Med 2018; 91:185-190. [PMID: 29955223 PMCID: PMC6020730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The consumption of sugary beverages (SBs) has increasingly grown in many countries and is a significant contributor to the rise in obesity and non-communicable diseases (NCDs). In response, public health officials in multiple countries have pushed for implementing a tax on SBs in order to reduce their consumption. Today, many individuals, especially those of lower socioeconomic status, live in environments in which unhealthy foods and drinks are more accessible than healthier ones. The beverage industry has greatly contributed to the formation of these "obesogenic" environments through their extensive advertising activities and effective marketing strategies. With rising public awareness of sugar's link to obesity, the industry has heavily invested in campaigns that seek to shift the blame away from their products and has aggressively opposed legislative efforts to pass an SB tax. This perspective will focus on explaining the rationale and necessity of an SB tax by highlighting the tactics the beverage industry has employed that have contributed to the formation and maintenance of the present unhealthy food environment.
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Affiliation(s)
- Matthew Du
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Aviva Tugendhaft
- PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,To whom all correspondence should be addressed: A. Tugendhaft, PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Agnes Erzse
- PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen J. Hofman
- PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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