Putting equity in health back onto the social policy agenda: experience from South Africa

Over the past decade, international health policy debates have been dominated by efficiency considerations. There has been a recent resurgence of interest in health equity, including consideration of the notions of vertical equity and procedural justice. This paper explores the possible application of these notions within the context of South Africa, a country in which inequities in income and social service distribution between 'racial' groups were systematically promoted and entrenched during four decades of minority rule, guided by apartheid and related policies. With the transition to a democratic government in 1994, equity gained prominence on the South African social policy agenda. Health equity has been awarded a particularly high priority, not least of all because the health sector is seen as vehicle for achieving rapid equity gains. In addition, many of the other equity-promoting social sector policies (such as improved access to housing and water and sanitation services) have been motivated on the basis of their potential health equity gains. The South African experience since 1994 provides useful insights into factors which may facilitate or constrain health equity progress. In particular, the constitutional entitlement to health and civil society action to maintain health equity's place on the social policy agenda are seen as important facilitating factors. Certain health sector programmes have also been developed which are intended preferentially to benefit those who have been historically dis-advantaged, and which thus support vertical equity goals. However, there have been no efforts to promote cross-subsidisation between the private and public health sectors, and initial efforts to promote coherency in social policies (through the Reconstruction and Development Programme) appear not to have been sustained. In addition, macro-economic policies (particularly the highly ambitious budget deficit reduction targets of the government) are likely to undermine some of the equity-promoting social policy initiatives. Most importantly, the potential inter-relationship of vertical equity and procedural justice goals has not been adequately recognised. As a result, and despite policy rhetoric, this paper concludes that health equity goals are critically dependent on the central involvement of the dis-advantaged in decision-making about who should receive priority, what services should be delivered and how equity-promoting initiatives should be implemented.     

Unusual presentation of perirenal lung metastases

Lung cancer is not commonly known to metastasise to the perirenal space, with only five such cases previously published. We present an unusual case of perirenal lung metastases manifesting as diffuse perinephric stranding which to our knowledge has not been described before.     

Breast cancer cell lines: friend or foe?

The majority of breast cancer research is conducted using established breast cancer cell lines as in vitro models. An alternative is to use cultures established from primary breast tumours. Here, we discuss the pros and cons of using both of these models in translational breast cancer research.     

The equity impacts of community financing activities in three African countries

Although the Bamako Initiative from its very beginning was caught up in wider debates about the potential equity impact of any form of user financing, to date there has been little empirical investigation of this impact. This three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, was initiated to add to the body of relevant evidence. It sought to understand not only what had been the equity impacts of community financing activities in these countries but also how they had been brought about. As a result, it investigated equity primarily through consideration of the design of these financing activities and through the perceptions of different actors, within a limited number of purposively selected geographical areas in each country, about their strengths and weaknesses. Additional data on utilization were either collected during the course of the study (Kenya) or drawn from other available studies (Benin and Zambia). Key issues considered in the studies' assessment of equity were the extent to which both relative and absolute affordability gains were achieved, as well as as an influence over both the distributional and procedural justice of the financing activities, the pattern of decision-making. Across countries there was evidence of relative affordability gains in Benin and Kenya, but Kenyan gains were not sustained over time and no such gains were identified in Zambia. In addition, no country had given attention either to the issue of absolute affordability, through the implementation of effective exemption mechanisms to protect the poorest from the burden of payment, or to the establishment of community decision-making bodies that effectively represented the interests of all groups including the poorest. Overall, therefore, although the Benin Bamako Initiative programme might be judged as successful in terms of what appear to be its own equity objectives, the other two countries' schemes had clear equity problems even in these terms. The experience across countries also highlights the unresolved question of whether equity is concerned with the greatest good for the greatest number or with promoting the interests of the most disadvantaged.     

Paracetamol use, availability, and knowledge of toxicity among British and American adolescents

Paracetamol is the commonest agent employed in self poisoning, however it is not clear whether adolescents possess insight into the serious complications associated with its misuse. Using a one page questionnaire, the availability, usage, and knowledge of toxicity of paracetamol among 1147 American and British adolescents was assessed. Although 90% of all students recognised that paracetamol could kill, the great majority of students overestimated the lethal dose. In addition, while knowledge regarding side effects of paracetamol was poor the drug was widely available to, and used by, the study population. It is proposed that gross overestimation of the number of tablets required to kill, poor understanding of paracetamol side effects, and wide availability of the drug contribute to its frequent use in adolescent suicidal behaviour. The inclusion of some over-the-counter medications in school drug education programs in addition to tighter control of the availability of paracetamol may help reduce the problem of adolescent self poisoning.     

Screening for a raised rectal temperature in Africa

The main purpose of this study was to compare rectal and axillary temperature measurements in African children. Altogether 573 sick children were seen in an outpatient setting in rural West Africa. Rectal and axillary temperatures were measured and the parent or guardian was asked if they thought that the child had a raised body temperature. Normal ranges were defined from an age matched population of 203 healthy children. A raised axillary temperature predicted a raised rectal temperature with a sensitivity of 98% and a specificity of 88%. The parents' impression that their child had a fever was a less sensitive (89%) and less specific (59%) indicator of raised rectal temperature. A raised axillary temperature is a good screening test for a raised rectal temperature in African children.     

Right heart pressure determination by Doppler in infants with tricuspid regurgitation

Doppler and direct measurements of right ventricle to right atrial pressure drop were made during cardiac catheterisation on 28 occasions in 26 infants with congenital heart disease. Age was 10 days to 12 months (median 4.5 months), and weight was 3.1 to 9.0 kg (median 4.7 kg). We measured peak velocity of tricuspid regurgitation by continuous wave Doppler, and the pressure drop was calculated using the modified Bernoulli equation (delta p = 4v2). There was a high correlation (r = 0.95) between direct and Doppler measurements. Doppler values tended to underestimate the right ventricle to right atrial pressure drop, but this was not of clinical significance (mean 2 mm Hg). The 95% confidence interval for the Doppler velocity was -0.41 to +0.26 m/sec, and was consistent across the range of pressures studied. Variability between observers was tested, by two observers performing sequential paired examinations on 16 newborn babies with tricuspid regurgitation. The coefficient of repeatability was 6.3 mm Hg (95% confidence interval 4.7 to 9.5 mm Hg) or 0.26 m/sec (0.18 to 0.50 m/sec). This method of right ventricular pressure estimation, validated previously only in older children and adults, is a reproducible and accurate technique in infants with tricuspid regurgitation.     

Interpretation of random urinary catecholamines and their metabolites in neuroblastoma

O'Meara A, Tormey W, Fitz Gerald RJ, Fitzgibbon M, Kenny D. Interpretation of random urinary catecholamines and their metabolites in neuroblastoma. Acta Paediatr 1994;83:88–92. Stockholm. ISSN 0803–5253
This study reports experience in the estimation of urinary catecholamines (uCATs) and their metabolites in the diagnosis and follow-up of neuroblastoma. Random urine samples were assayed for dopamine, noradrenaline and adrenaline, together with their metabolites 4-hydroxy 3-methoxyman-delic acid (HMMA) and homovanillic acid (HVA), using HPLC with electrochemical detection. Twenty of 21 patients had elevation of one or more uCATs metabolites at diagnosis. Patients were monitored serially from diagnosis and, in those patients who had delayed resection of primary tumour (n=13), particular attention was paid to levels at the pre-surgical evaluation as an indicator of persistence of viable disease at the time of surgery; dopamine proved to be the most accurate indicator of persistent disease at this time. Five of these patients developed recurrent disease, 4 of whom had elevation of two or more uCATs metabolites at the time of relapse. Several conclusions can be drawn from this study: (a) results for HMMA, HVA and dopamine in random urine samples will detect all but the most biochemically immature or inert tumours; (b) dopamine may be the most reliable indicator of persistent disease and (c) noradrenaline and adrenaline measurements were of little benefit. As results are Expressed in relation to urinary creatinine, excretion of which may be affected by dietary protein and is therefore not constant, borderline results should be repeated.     

Liposomal amphotericin B in hepatic candidosis

A 4 year old girl treated with a standard chemotherapy protocol for acute lymphoblastic leukaemia developed hepatic candidosis during the consolidation phase. This relapsed after a prolonged course of amphotericin B and flucytosine. An eight week course of liposomal amphotericin produced a marked clinical improvement which was sustained for one year. A subsequent relapse was associated with transformation to myelodysplastic leukaemia.     

Surgical anatomy of the nose

It is imperative to know the details of the anatomy of the nose before understanding any surgical procedure performed on the nose. The details presented in this article should help the experienced and the novice surgeon accomplish the difficult task of a rhinoplasty.