published_or_final_version / Community Medicine / Master / Master of Public Health

A large number of people all over the world suffer from skin conditions. Dermatological problems comprise about 10 % of a general practitioner's caseload and probably more for pharmacists. The literature furthermore emphasises that skin diseases are becoming a significant problem in the developing world. There is a need to establish an effective method to achieve good health and quality of life for patients with dermatological problems. The general objective of this study was to investigate the usage patterns and cost of dermatological products in the private health care sector of South Africa by using a medicine claims database. The focus was specifically on dermatological products with a prevalence of more than 10 % in the database. A quantitative retrospective drug utilisation research design was used to evaluate the usage patterns and costs of dermatological products in three four-monthly intervals of 2001 and 2004. Data were analysed by using the Statistical Analysis System, 9.1 (SAS). The dermatological product groups for this study were antibacterial and antifungal drugs, corticosteroids and anti-acne products and were analysed according to the MIMS classification. Of all analysed prescriptions issued only 8.57 % (n = 126 447) during 2001 (N = 1 475 380) and 6.82 % (n = 177 122) during 2004 (N = 2 595 254) consisted of dermatological products. Of the total number of products prescribed, the dermatological products constituted 4.77 %I (n = 140 701) for 2001 (N = 2 95 1 326) and 3.77 % (n = 199 976) for 2004 (N = 5 305 882). The total cost of the dermatological products was 4.98 % (n = R18 913 889.92) of the total cost of all medicine products during 200 1 (N = R379 708 489). During 2004 (N = R66 1 223 146) the total cost of dermatological products was 4.09 % (n = R27 025 540.48) of the total cost of all medicine products in the database. The cost-prevalence index for 2001 and 2004 respectively showed that the dermatological products were relatively expensive with values of 1.03 and 1.09. The antibacterial and antifungal drugs, corticosteroids and anti-acne products represented 91.92 % (n = 129 336) and 87.97 % (n = 175 9 16) of all dermatological products during 2001 (N = 140 701) and 2004 (N = 199 976), respectively. These dermatological groups named above represented 91.57 % (n = R17 319 645.61) and 85.85 '% (n = R23 200 594.71), respectively, of the total cost of dermatological products during 200 1 (N = R18 9 13 889.92) and 2004 (N = R27 025 540.48). It was further found that the majority of dermatological products prescribed during the research periods was innovator products. The prevalence of innovator products for 2001 was 86.17 % (n = 12 1 249) with a total cost representing 94.16 % (n = R17 809 603.12). For 2004 the prevalence was 82.33 % (n = 164 640) with a total cost representing 91 .O1 '% (n = R24 594 923.72) of all the dermatological products prescribed. The number of innovator and generic products claimed during 2001 amounted to 86.17 % (n = 12 1 249) and 13.83 % (n = 19 452) respectively of the total number of products claimed (N = 140 701). During 2004 the number of innovator and generic products represented respectively 82.33 % (n = 164 640) and 17.67 O/o (n = 35 336) of the total number of products claimed (N = 199 976). The prevalence in the use of the dermatological products during 2004 increased with 55.25 % from January to April versus September to December. The cost-prevalence index indicated that the dermatological products were relatively expensive during January to August 2004. During September to December 2004 the cost-prevalence decreased and indicated that dermatological products became inexpensive. The average cost of dermatological products during the 2004 study period showed that the cost decreased. January to April (before implementation of the new single exit price structure) was compared to September to December (after implementation of the new single exit price structure). This comparison indicated that the average cost decreased by 22.88 %. It can be summarised that the average cost in the last study period decreased due to the changed price structure. The innovator products' prevalence was high and therefore more generics are needed in dermatology. If more generics are used the total cost of dermatological products might also decrease. The number of dermatological prescriptions increased towards 2004, but this may be because of more members or more medical aids claiming through this database. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2006.

A large number of people all over the world suffer from skin conditions. Dermatological problems comprise about 10 % of a general practitioner's caseload and probably more for pharmacists. The literature furthermore emphasises that skin diseases are becoming a significant problem in the developing world. There is a need to establish an effective method to achieve good health and quality of life for patients with dermatological problems. The general objective of this study was to investigate the usage patterns and cost of dermatological products in the private health care sector of South Africa by using a medicine claims database. The focus was specifically on dermatological products with a prevalence of more than 10 % in the database. A quantitative retrospective drug utilisation research design was used to evaluate the usage patterns and costs of dermatological products in three four-monthly intervals of 2001 and 2004. Data were analysed by using the Statistical Analysis System, 9.1 (SAS). The dermatological product groups for this study were antibacterial and antifungal drugs, corticosteroids and anti-acne products and were analysed according to the MIMS classification. Of all analysed prescriptions issued only 8.57 % (n = 126 447) during 2001 (N = 1 475 380) and 6.82 % (n = 177 122) during 2004 (N = 2 595 254) consisted of dermatological products. Of the total number of products prescribed, the dermatological products constituted 4.77 %I (n = 140 701) for 2001 (N = 2 95 1 326) and 3.77 % (n = 199 976) for 2004 (N = 5 305 882). The total cost of the dermatological products was 4.98 % (n = R18 913 889.92) of the total cost of all medicine products during 200 1 (N = R379 708 489). During 2004 (N = R66 1 223 146) the total cost of dermatological products was 4.09 % (n = R27 025 540.48) of the total cost of all medicine products in the database. The cost-prevalence index for 2001 and 2004 respectively showed that the dermatological products were relatively expensive with values of 1.03 and 1.09. The antibacterial and antifungal drugs, corticosteroids and anti-acne products represented 91.92 % (n = 129 336) and 87.97 % (n = 175 9 16) of all dermatological products during 2001 (N = 140 701) and 2004 (N = 199 976), respectively. These dermatological groups named above represented 91.57 % (n = R17 319 645.61) and 85.85 '% (n = R23 200 594.71), respectively, of the total cost of dermatological products during 200 1 (N = R18 9 13 889.92) and 2004 (N = R27 025 540.48). It was further found that the majority of dermatological products prescribed during the research periods was innovator products. The prevalence of innovator products for 2001 was 86.17 % (n = 12 1 249) with a total cost representing 94.16 % (n = R17 809 603.12). For 2004 the prevalence was 82.33 % (n = 164 640) with a total cost representing 91 .O1 '% (n = R24 594 923.72) of all the dermatological products prescribed. The number of innovator and generic products claimed during 2001 amounted to 86.17 % (n = 12 1 249) and 13.83 % (n = 19 452) respectively of the total number of products claimed (N = 140 701). During 2004 the number of innovator and generic products represented respectively 82.33 % (n = 164 640) and 17.67 O/o (n = 35 336) of the total number of products claimed (N = 199 976). The prevalence in the use of the dermatological products during 2004 increased with 55.25 % from January to April versus September to December. The cost-prevalence index indicated that the dermatological products were relatively expensive during January to August 2004. During September to December 2004 the cost-prevalence decreased and indicated that dermatological products became inexpensive. The average cost of dermatological products during the 2004 study period showed that the cost decreased. January to April (before implementation of the new single exit price structure) was compared to September to December (after implementation of the new single exit price structure). This comparison indicated that the average cost decreased by 22.88 %. It can be summarised that the average cost in the last study period decreased due to the changed price structure. The innovator products' prevalence was high and therefore more generics are needed in dermatology. If more generics are used the total cost of dermatological products might also decrease. The number of dermatological prescriptions increased towards 2004, but this may be because of more members or more medical aids claiming through this database. / Thesis (M.Pharm.)--North-West University, Potchefstroom Campus, 2006.

Acne is a very common disease affecting approximately 85% of people in some stage of their life (Wolff et al., 2005:2). The systemic drug isotretinoin is the only acne drug which has an influence on all the pathophysiological factors of this highly prevalent disease and is considered as the most effective treatment for acne, although it should be limited to the treatment of severe acne. Isotretinoin prescribing is under the largest risk-minimisation programme (called iPLEDGE) ever implemented for a drug in the United States of America, due to concerns with pregnancies during isotretinoin treatment (Honein et al., 2007:11). In comparison South Africa has no equal managing programme to regulate isotretinoin prescribing and the need to identify certain prescribing patterns is deemed necessary. The general objective of this study was to analyse the prescribing patterns of isotretinoin, including aspects of cost, in a section of the private healthcare sector of South Africa. A quantitative, retrospective drug utilisation review was performed to evaluate the prescribing patterns and cost of isotretinoin containing products claimed through a pharmacy benefit management organisation, over the study period of 2005 and 2006. Data were analysed by using the Statistical Analysis System, 9.1 (SAS). The information of prescriber, age, gender, and cost of isotretinoin usage were considered and evaluated. A total number of 6 427 and 6 927 patients claimed 18 589 and 20 232 isotretinoin prescriptions respectively during 2005 and 2006. Isotretinoin total costs contributed to 34.4% (n = R6 810 090) and 36.3% (n = R6 533 241) of the total identified acne medicine costs for 2005 and 2006 respectively. Isotretinoin represented the highest percentage of total costs in relation to any other acne product identified in both study years. Average costs of R314.82 ± 205.92 per prescribed isotretinoin item in 2005 and R277.63 ± 192.63 in 2006 were recorded in comparison to the total database medicine item cost of R95.33 ± 192.21 in 2005 and R95.33± 227.99 in 2006. The generic products of isotretinoin were claimed at a lower ratio (generic vs. innovator product ratio of 1.8:1 in 2005 and 2.2:1 in 2006) in relation to the total database (generic ratio of 3:1 in both years). Dermatologists prescribed 68.2% and 65.7% of isotretinoin prescriptions and general practitioners 27.5% and 29.7%. General practitioners were more likely to prescribe the generic equivalents of isotretinoin (68.9% in 2005 and 72.1% in 2006) in comparison to dermatologists (59.7% in 2005 and 63.4% in 2006). The teenage group 12 to 19 years received 48.4% (n = 8 989) and 47.7% (n = 9 656) of isotretinoin prescriptions claimed respectively at an estimated cost of R275 000 and R260 000 per 10 000 beneficiaries in this age group respectively for 2005 and 2006. There were 71 patients identified over both study years in the age group younger than 12 years, in which isotretinoin use is not recommended. Female patients received 56.2% (n = 10 450) and 57.4% (n = 11 610) of the total number of isotretinoin prescriptions claimed respectively for 2005 and 2006. The average cost per isotretinoin prescription claimed for male patients was higher (R406.36 ± 233.76 and R358.69 ± 218.29 respectively for 2005 and 2006) in relation to female patients (R335.15 ± 209.98 and R296.36 ± 197.74 respectively for 2005 and 2006). The median ages for female and male patients were 21 years and 18 years respectively. The concern, however, was the high number of female patients of child-bearing potential identified (2 892 and 3 201 female patients respectively for 2005 and 2006), claiming their isotretinoin prescriptions. Systemic isotretinoin occurred alone in 70.8% and 69.3% of prescriptions claimed respectively for 2005 and 2006. Oral contraceptives occurred in combination with isotretinoin in only 8.6% and 9.2% of isotretinoin prescriptions claimed. The contra-indicated use of a systemic tetracycline in combination with systemic isotretinoin occurred in 139 (0.75%) and 130 (0.64%) prescriptions. It can be concluded that the use of isotretinoin increased. Dermatologists played the major role in prescribing isotretinoin. The number of female isotretinoin users (especially of child-bearing potential) could be a concern, although pregnancy prevalence should be identified in South Africa. It is recommended that further studies be conducted in South Africa regarding the usage and control of isotretinoin, including the extension of regulating programmes, with special reference to age and gender. Effective management of the increasing popularity of this ultimately successful acne treatment is of utmost importance to ensure the effective and safe usage of isotretinoin. / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

Acne is a very common disease affecting approximately 85% of people in some stage of their life (Wolff et al., 2005:2). The systemic drug isotretinoin is the only acne drug which has an influence on all the pathophysiological factors of this highly prevalent disease and is considered as the most effective treatment for acne, although it should be limited to the treatment of severe acne. Isotretinoin prescribing is under the largest risk-minimisation programme (called iPLEDGE) ever implemented for a drug in the United States of America, due to concerns with pregnancies during isotretinoin treatment (Honein et al., 2007:11). In comparison South Africa has no equal managing programme to regulate isotretinoin prescribing and the need to identify certain prescribing patterns is deemed necessary. The general objective of this study was to analyse the prescribing patterns of isotretinoin, including aspects of cost, in a section of the private healthcare sector of South Africa. A quantitative, retrospective drug utilisation review was performed to evaluate the prescribing patterns and cost of isotretinoin containing products claimed through a pharmacy benefit management organisation, over the study period of 2005 and 2006. Data were analysed by using the Statistical Analysis System, 9.1 (SAS). The information of prescriber, age, gender, and cost of isotretinoin usage were considered and evaluated. A total number of 6 427 and 6 927 patients claimed 18 589 and 20 232 isotretinoin prescriptions respectively during 2005 and 2006. Isotretinoin total costs contributed to 34.4% (n = R6 810 090) and 36.3% (n = R6 533 241) of the total identified acne medicine costs for 2005 and 2006 respectively. Isotretinoin represented the highest percentage of total costs in relation to any other acne product identified in both study years. Average costs of R314.82 ± 205.92 per prescribed isotretinoin item in 2005 and R277.63 ± 192.63 in 2006 were recorded in comparison to the total database medicine item cost of R95.33 ± 192.21 in 2005 and R95.33± 227.99 in 2006. The generic products of isotretinoin were claimed at a lower ratio (generic vs. innovator product ratio of 1.8:1 in 2005 and 2.2:1 in 2006) in relation to the total database (generic ratio of 3:1 in both years). Dermatologists prescribed 68.2% and 65.7% of isotretinoin prescriptions and general practitioners 27.5% and 29.7%. General practitioners were more likely to prescribe the generic equivalents of isotretinoin (68.9% in 2005 and 72.1% in 2006) in comparison to dermatologists (59.7% in 2005 and 63.4% in 2006). The teenage group 12 to 19 years received 48.4% (n = 8 989) and 47.7% (n = 9 656) of isotretinoin prescriptions claimed respectively at an estimated cost of R275 000 and R260 000 per 10 000 beneficiaries in this age group respectively for 2005 and 2006. There were 71 patients identified over both study years in the age group younger than 12 years, in which isotretinoin use is not recommended. Female patients received 56.2% (n = 10 450) and 57.4% (n = 11 610) of the total number of isotretinoin prescriptions claimed respectively for 2005 and 2006. The average cost per isotretinoin prescription claimed for male patients was higher (R406.36 ± 233.76 and R358.69 ± 218.29 respectively for 2005 and 2006) in relation to female patients (R335.15 ± 209.98 and R296.36 ± 197.74 respectively for 2005 and 2006). The median ages for female and male patients were 21 years and 18 years respectively. The concern, however, was the high number of female patients of child-bearing potential identified (2 892 and 3 201 female patients respectively for 2005 and 2006), claiming their isotretinoin prescriptions. Systemic isotretinoin occurred alone in 70.8% and 69.3% of prescriptions claimed respectively for 2005 and 2006. Oral contraceptives occurred in combination with isotretinoin in only 8.6% and 9.2% of isotretinoin prescriptions claimed. The contra-indicated use of a systemic tetracycline in combination with systemic isotretinoin occurred in 139 (0.75%) and 130 (0.64%) prescriptions. It can be concluded that the use of isotretinoin increased. Dermatologists played the major role in prescribing isotretinoin. The number of female isotretinoin users (especially of child-bearing potential) could be a concern, although pregnancy prevalence should be identified in South Africa. It is recommended that further studies be conducted in South Africa regarding the usage and control of isotretinoin, including the extension of regulating programmes, with special reference to age and gender. Effective management of the increasing popularity of this ultimately successful acne treatment is of utmost importance to ensure the effective and safe usage of isotretinoin. / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

Thesis (MBA (Business Management))--University of Stellenbosch, 2009. / ENGLISH ABSTRACT: South Africa is on the verge of major changes in the private medical sector. The government’s planned National Health Insurance has far reaching implications for all role players in the industry, as well as for the general public. This paper looks at the changes that have been made since the ANC government came to power in 1994 and then continues to look at possible models for the new National Health Insurance plan. A proposal on practicing cost-effective cardiology within this new system is made. The data of a pilot project between a private service provider and a managed healthcare company is analysed as a basis of this discussion. / AFRIKAANSE OPSOMMING: Suid-Afrika se mediese bedryf staan op die vooraand van groot veranderinge. Die regering se beplande Nasionale Gesondheidsplan het verreikende implikasies vir alle rolspelers in die bedryf, sowel as die algemene man op straat. Die dokument kyk oorsigtelik na die veranderinge wat ondergaan is sedert die ANC regering aan bewind gekom het in 1994 en gaan daarna voort om na moontlike opsies te kyk hoe die nuwe gesondheidsmodel daarna gaan uitsien. Voorstelle word gemaak oor hoe privaat kardiologie in die nuwe sisteem koste-effektief beoefen kan word. ‘n Lootsprojek van ‘n privaat diensverskaffer en ‘n bestuurde gesongheidsorg maatskappy se data word ontleed as basis vir die bespreking.

published_or_final_version / Community Medicine / Master / Master of Public Health

Farmyard runoff, i.e. the effluent generated by the rain falling over farmyards, tracks and roofs, is a significant and overlooked source of nutrients and pathogens which degrades aquatic ecosystems through eutrophication, siltation and wildlife poisoning, raises public health concerns, and incurs considerable costs for society. Among other Best Management Practices implemented to address agricultural water pollution and help achieve compliance with the Water Framework Directive, Constructed Farm Wetlands (CFWs), i.e. shallow surface flow wetlands comprising several vegetated cells in series, are being recommended for remediation of farmyard runoff, due to their capacity to remove or store pollutants. Investigation is therefore needed of their long-term water treatment efficiency and ecological value to optimize their design and cost-effectiveness and minimize their negative externalities. The main aims of this study were to: 1) evaluate the treatment performance of CFWs and the link between design, hydrology and efficiency; 2) assess their ecological value and the influence of water quality and design on wetland ecology; 3) identify their costs, benefits and the way they are perceived by farmers; and 4) inform guidelines for the design, construction and aftercare of sustainable CFWs. Research focused on two CFWs in south-east Scotland, one at a dairy farm and one at a mixed beef-arable farm, which receive runoff from yards and roofs, field drainage and septic tank overflow. From February 2006 to June 2008, rainfall, evaporation, water levels and flow at the CFWs were monitored, and their treatment efficiency was assessed from water samples collected manually regularly or with automatic samplers during storm events, and analysed using standard methods. In addition, their ecological value was assessed twice a year from vegetation and aquatic macroinvertebrate surveys. Finally, semi-structured interviews with eight farmers and a farm advisor and discussions with three CFW designers in Scotland and Ireland allowed collection of technical and economic data on farm practices, CFW construction and maintenance, and helped assess CFW cost-effectiveness and acceptance by farmers. Both CFWs reduced pollutant concentrations between inlet and outlet, with efficiencies at CFW1 and CFW2 respectively of 87% and < 0% for five-day biochemical oxygen demand, 86% and 83% for suspended solids, 68% and 26% for nitrate/nitrite, 42% and 34% for ammonium, and 12% and 31% for reactive phosphorus. Nevertheless, the concentration of all pollutants at the outlet of CFW1, and concentration of nitrate/nitrite at the outlet of CFW2 frequently exceeded river water quality standards. Water treatment efficiency varied seasonally, being significantly lower in winter, mainly due to lower temperatures, increased volume of inputs and reduced residence time. The ecological value of the two CFWs differed greatly. At CFW1 and CFW2 respectively, 14 and 22 wetland plant species and 24 and 46 aquatic macroinvertebrate species (belonging to 13 and 27 BMWP scoring families respectively) were recorded, illustrating the greater biodiversity conservation value of CFW2, which was one year older, larger, cleaner, comprised several ponds with a combination of open water and densely vegetated areas, and was subsequently more structurally diverse. The socio-economic study revealed that, despite significant costs associated with their construction (£20 000-£50 000 ha-1) and maintenance (£900-£1500 ha-1 yr-1), CFWs may still represent a more cost-effective alternative than conventional methods. However, their adoption, implementation and sustainable use by farmers were conditioned by land availability and suitability, existing farm infrastructure, detailed information on limitations and maintenance requirements, and adequate financial support for both construction and aftercare. To ensure a long-term, consistent and efficient water treatment, and to enhance biodiversity and landscape, well-maintained, large, vegetated, multi-cell CFWs with shallow overflows are recommended. Their size should be adapted to local precipitation patterns and catchment characteristics. Keywords: agriculture, best management practice (BMP), biodiversity, constructed farm wetland (CFW), costs, farmyard runoff, water pollution, water treatment.

Thesis (M. Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.

More people living with HIV/AIDS reside in South Africa than any other country in the world, and the nation faces colossal challenges in broadening its response to the now-mature and widespread HIV epidemic (WHO, 2005:1). According to South Africa's Medical Research Council, HIV/AIDS has now become the single largest cause of death in South Africa (Dorrington et a/., 2001:6) and has triggered a prominent transferal in the pattern of mortality from the elderly to the young, particularly among young women (Dorrington, 2001:4). The routine treatment of HIV/AIDS with antiretroviral drugs has transformed HIV-infection from an unvaryingly rapidly terminal illness to a somewhat expensive treatable, chronic disease. Triple therapy or highly active antiretroviral therapy (three-drug combinations of ARVs or HAART) in particular have had paramount impacts on HIV-related morbidity and mortality in settings where these drugs are generally accessible. Objectives of ARV treatment are "maximum, durable suppression of viral load, restoration and/or preservation of immune function, improvement of quality of life and reduction of HIV related morbidity and mortality" (Martinson et a/., 2003:236; Martinez et a/., 2007:251; Hellinger, 2006:1; Kumarasamy, 2004:3). The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that a total of 111 827 South Africans were accessing free antiretroviral treatment in the 200 public health sector facilities across 53 districts and a further 60 000 via the private sector by late December 2005 (UNAIDS, 2005:1). The objective of this study was to review, analyse and interpret the usage and prescribing patterns of antiretroviral drugs in a section of the South African private health care sector for the period 1 January 2005 to 31 December 2006 by utilising a medicine claims database of a pharmacy benefit management company, and to investigate the costs associated with these drugs by performing a quantitative, retrospective drug utilisation review. It was found that the prevalence as well as the total medicine cost of ARV medicine items had increased during the study period but the average number of ARV medicine items per prescription as well as both the average cost per ARV medicine item and the average cost per ARV prescription decreased during the study period. Original innovator ARV medicine items and original ARV medicine items with no generic were found to be relatively expensive in comparison with ARV medicine items in general. Conversely, generic ARV medicine items were ascertained to be relatively inexpensive with reference to ARV medicine items in general. It was perceived that the average cost of ARV medicine items and prescriptions for both genders decreased from 2005 to 2006, while there was an increase in the prevalence of medicine items and prescriptions claimed for both female and male patients. The prevalence and cost of all types of ARV medicine items were found to be higher for female patients in general. It was also established that the prevalence of patients receiving antiretroviral treatment in the private health care sector peaks at the age of >30 to 244 years, in comparison with the lower age of >25 to 239 years in the public health care sector. ARV medicine items claimed for patients in the age group >35 to 239 years represented the highest percentage of the total medicine cost incurred during both study years for all ARV medicine types. The majority of ARV medicine items were prescribed by general medical practitioners, and most ARV medicine items were dispensed by community or private institutional pharmacies. It was determined that combinations of 2NRTI + NNRTI were prescribed with the highest frequency, which is compliant with traditional HAART or 'triple therapy' regimens. Lastly, it was found that none of the top 20 prescriptions for one, two and six ARV medicine items were compliant with the National Antiretroviral Treatment (ART) Guidelines. The majority of the top 20 prescriptions for three ARV medicine items (92.67 per cent during 2005 and 89.94 per cent during 2006) were compliant with the National ART Guidelines. Finally, less than half of the top 20 prescriptions for four ARV medicine items (49.60 per cent during 2005 and 36.11 per cent during 2006) were compliant with the National ART Guidelines. Only 5.56 per cent and 3.92 per cent of the top 16 prescriptions for five ARV medicine items were compliant with the National ART Guidelines during the two study years respectively / Thesis (M. Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2009.