Patient safety is an important element of an effective and efficient health care system. Safety refers to a lack of harm while quality has to do with efficiency and effectiveness that achieves the goal of healthcare at the right cost and at the right time. As such safety focuses on avoiding adverse events and reducing the likelihood that they will happen while quality focuses on doing things well and improving the patient experience. How does this relate to healthcare in South Africa today?
The National Minister of Health, Dr. Aaron Motsoaledi, is rightly credited with extricating South Africa from the denialist AIDS debacle in South Africa and his dedication to improving healthcare for South Africans is undeniable. Certainly, the provision of anti-retroviral drugs recently extended to all those who test positive for the HI virus is a major advance, but unfortunately there are continued and oft publicized failures of public sector hospitals and clinics to provide quality and safe health care.
The private health sector in South Africa, which provides healthcare perceived by many to be of high quality and standard in conditions that are generally safe and more acceptable, is attacked as profligate and unaffordable for the majority. This is the driving motivation for the Competition Commission market enquiry into private healthcare currently underway. Indeed, it is essential that every “health rand” be appropriately and effectively utilized both in the private and the public sectors. However, a pertinent question that remains is whether the funds allocated to the public sector provide the value for money that they should to the under-served majority in the country. If not, then what is the reason?
South Africa spends an estimated 8,8% of the GDP (2012) on healthcare slightly below the average of 9.3% of the OECD countries. However, in South Africa the public share of 48% differs from the comparable OECD figure of 72% and is comparable with countries such as Chile, Mexico and the United States.
The total public-sector health budget in 2016 was reported as R168,4 billion. This provides health care for predominantly the approximately 40 million uninsured population of South Africa, which amounts to around R4200 annually per head of the uninsured population. In contrast this compares poorly, around three and a half fold less, with those contributing to one or other form of medical insurance or making out of pocket payments with an annual average estimated expenditure of R180 billion amounting to an annual R11 000 per capita expenditure.
While the stark difference between the per capita expenditure on health is an easy answer to the criticism of the differences between the public and private health service delivery, would a simple redistribution of the total national expenditure on healthcare in this country result in safe and quality healthcare in the South African public sector? Certainly, this difference has an impact on the level, quality and safety of services that are provided in the public sector compared with that provided by the private sector but there are other factors that impact on the challenges faced by the South African public health sector.
An essential factor that will ensure the maximal cost-effective utilization of every scarce health rand is how the available resources are distributed and managed. South Africa and indeed many other countries are challenged by a lack of management and administrative capacity in many sectors and if this is not addressed an increased allocation of funding will not necessarily impact positively on the safety and quality of healthcare experienced by the average citizen in their countries.
South Africa as a result of its unique history inherited a health system, that following the democratic transition in 1994 apart from an inequitable distribution of health care services lacked not only the number of health professionals required to deliver healthcare in the public sector but, in addition, lacked the managerial capacity and expertise required to transform and manage the health service. Many of the ambitious and far-sighted plans and policies since 1994 have under-estimated the management capacity and skills needed to implement them. Despite the best intentions of many committed individuals the outcome has fallen short of the optimistic expectations of the early years of South Africa’s fledgling democracy.
It is not all doom and gloom and there have been successes along the way as evidence by a gradual but steady improvement of the country’s health indices possibly not due to the health system alone, such as life expectancy, infant and maternal mortality despite the concomitant ravages of the AIDS epidemic. But could it have been so much better and if so what could have to make it so?
One approach to the failure to deliver safe and quality healthcare is to regulate the sector and the establishment of the Office of Health Standards Compliance (OHSC) is an attempt to do so. The OHSC as part of its mandate certifies and inspects health care institutions, ensuring that they comply with stringent standards of providing quality health care. What is noteworthy of the OHSC and other attempts to address safety and quality of health care, is that, while important, other than identifying the deficiencies themselves, they have not addressed the underlying causation of the deficiencies reinforced by the fact that rather than improve many facilities have reflected a negative trend in OHSC assessments undertaken over the last few years.
My experience heading two South African provincial public-sector health departments since 1994 indicates that the finger can be pointed at the lack of management and administrative capacity at all levels of the health system as a significant cause of the failure of this sector to perform. This opinion has been strengthened with my involvement in assessing the functioning of hospitals in several provinces over the last two years where many of the negative findings, related to unsafe conditions and poor-quality healthcare have their origin in poor management and administrative capacity. In my view, the answer is to address the underlying management and administrative deficiencies rather than increased regulation.
If lack of management and administrative capacity is indeed a significant cause of the failure to perform there is a measure of reassurance in this fact since management and administration are eminently learnable and teachable skills and there is remains a critical mass of people and organizations in South Africa that can step up to the plate and deliver. Management must have an in-depth understanding of what systems and processes are required to make a large organization function efficiently, be able to determine priorities, take decisions and be held accountable for the decisions taken. Management requires the insight and confidence that results from experience but also a supportive environment in which to develop.
An Academy of Health Leadership and Management has for some years been envisaged by the National Department of Health but even if an institution of this nature has the necessary capacity to impart both theoretical and practical skills, it alone cannot be successful in filling the current management vacuum. However, if all the management expertise, systems and administrative practices available currently both in the private and public sector were to be focused on the under performance of the South African public health system, in my view, the underperformance could be reversed within a relatively short time frame.
There is a view that there is a wide gulf between the public and private health sectors and that the two sectors operate in different worlds making cooperation difficult if not impossible. This is to an extent true, but as a result there is a tendency of the one to demonize or stereotype the other. If this gulf could be bridged with an acceptance of the value of each by the other, there is an opportunity to begin to make the total health system of South Africa to deliver a far better performance. What is required is a greater partnership and learning experience between public and private sector entities with both recognizing their differences but also their similarities.
The partnership envisaged requires a change of attitude and contributions from both sectors. On the part of the public sector it is essential that there is an acceptance that there is a problem and that assistance is required to solve it. On the part of the private sector, it is essential that there is a similar acceptance that the current situation is untenable in the longer term and that they too have a problem that requires a solution. The lofty ideals of universal access to health care as espoused in the National Health Insurance Policy document published in June 2017 will be unachievable without this acceptance and unless both sectors accept that they are inextricably linked in the struggle to deliver safe, affordable, quality healthcare to all South Africans.
The solution to the challenges in the South African health sector, in my view, lies in bringing the collective managerial expertise within the South African health sector to bear on the challenges faced by the public and private health sectors. Clearly some redirection of resources currently utilized for private health care in South Africa is inevitable, a fact emphasized by the ballooning of medical aid claims and ongoing increases in member contributions to these schemes. However, the partnership proposed would ensure that whatever funds are allocated to the public health sector achieve maximum delivery. This partnership will require a coming together across the current divide but in doing so the potential for benefit is massive.
The Operation Phakisa initiative adopted by government has brought together role-players to fast-track solutions to various pressing issues in various sectors in the country. The approach of the “Ideal Clinic” initiative was broad and all-encompassing and although the implementation has been patchy to date, it strengthens the argument for a collaborative approach to address the challenges faced by the South African health system. However, to promote delivery in the broader health services what is also needed is paradoxically a more focused approach with an emphasis on “hard” management issues. A well-directed, constructive dialogue leading to decision-making and action will enable just such a focused process to begin.
A key component of this interaction must be the participation of people and organizations with hands-on expertise and experience of the management of health services together with industry leaders responsible for the development and implementation of health policy both within the public and private sectors. It cannot be a theoretical or academic exercise. The intended outcome of this envisaged “health compact”, as I would describe it, would be concrete steps to address managerial deficiencies in the public sector utilizing all the resources available in both the public and private sectors to this end but within a viable business context for all concerned.
In conclusion, it may seem far-fetched to believe that this approach will solve all the challenges currently faced by the public health sector but in my view, it would certainly go some way to begin a process to urgently improve the quality and safety of health care in State health facilities across South Africa. In doing so it will take the country some way toward achieving the goal of “safe” and “quality” universal health coverage, that is the stated intention of the National Health Insurance.
Professor Keith Craig Househam who is former head of the Western Cape and Free State provincial health departments