Chapter 13
QUALITY OF CARE
Lilian Dudley, Rajesh Patel, Siphiwe Mndaweni, Thulani Masilela
Introduction
High-quality health systems are necessary for the achievement of Universal Health Coverage (UHC) and the United Nations Sustainable Development Goals (SDGs). UHC and the SDG goal 3, focusing on healthy lives and the promotion of well-being for all people, have renewed the impetus to address quality of care within health systems.1 In South Africa, the proposed National Health Insurance (NHI) system, which aims to improve access to quality health services for all South Africans, has renewed scrutiny of the quality of health care.2 More recently, the COVID-19 pandemic has further exposed the inequities and weaknesses in quality of care across health systems in South Africa.
Chapter 5 on ‘Improving Quality’ in the previous edition of South Africa Health Reform (2009 – 2014) reported on the development of National Core Standards (NCS), the establishment of the Office of Health Standards Compliance (OHSC) as promulgated by an Amendment to the National Health Act 2003 (NHA) in 2013, the findings of the National Baseline Health Facility Audit of 2010, the inspections of health establishments undertaken by the OHSC up to 2014, and briefly described a few quality improvement (QI) initiatives in South Africa.3
This edition of the South Africa Health Reforms reviews developments in the quality of health care in South Africa since 2015. We draw on the findings and recommendations of the 2019 South African Lancet National Commission (‘the Commission’) report, ‘Confronting the right to ethical and accountable quality health care in South Africa’, describe important developments since the publication of the report, and discuss barriers and opportunities for achieving a high-quality health system in South Africa post COVID-19.4
The Commission defined a high-quality health system as one which ‘achieves equitable health outcomes and a long and healthy life for all’, and developed a conceptual framework for a high-quality health system, underpinned by the values of human rights, equity and social justice for South Africa. The framework described a quality health system as being responsive to the South African context, and ensuring the achievement of key impacts and outcomes through the mobilisation of appropriate inputs, and service delivery under effective leadership and governance4 (Figure 13.1).
Figure 13.1 Conceptual framework for a high-quality South African health system
Source: Adapted from: van Olmen et al. (2012) and South African Lancet National Commission4,5
To complement this overarching health systems’ framework, the National Department of Health (NDoH) developed a National Quality Strategic Framework which specified the main domains of service delivery across the life-course, and the required inputs, processes, outputs, outcomes and impact to inform planning and assessment of such a quality health system. The NDoH framework also emphasised the importance of quality planning, quality control and assurance, and quality improvement, the three components of the Juran Triad6 (Figure 13.2).
The Commission found an enabling legal and policy environment, numerous QI initiatives, increased life expectancy and decreased mortality rates in South Africa. The report however identified significant challenges and threats, in particular: i) Gaps in ethical leadership, management and governance; ii) Poor quality of care costs lives; iii) Malpractice cases and medical litigation are threats; iv) the Human Resources for Health (HRH) crisis will undermine high-quality UHC; v) Health information system gaps, and vi) Fragmentation and limited impact of quality of care initiatives. Four overarching recommendations were to: i) Enhance governance and leadership for quality and equity; ii) Revolutionise quality of care; iii) Invest in and transform human resources in support of a quality health system; and iv) Measure, monitor and evaluate to ensure high-quality UHC.
The following sections summarise the Commission’s findings and recommendations, and review progress in moving the agenda of a high-quality health system in South Africa forward in a post COVID-19 pandemic context. Definitions of key concepts are provided below.
• Quality Control is used to determine where and when corrective action is required. It seeks to ensure that outcomes and services are of acceptable quality, free of errors and defects.
• Quality Improvement (QI) is broadly defined as a change process which should lead to better patient outcomes (health), better system performance (care) and better professional development (learning).7
• Certification is a process by which a recognised authority evaluates and recognises an individual provider, or an organisation as having met predetermined requirements.
• Accreditation is a formal process carried out by a recognised body and involves detailed and critical assessment of all aspects of a health care facility against a predetermined set of standards and criteria; and accreditation can be awarded if found to comply to a substantial degree.
Figure 13.2 Proposed National Strategic Framework6
Governance and leadership of quality
The SA Lancet Commission’s findings on governance
The Commission’s 2019 report concluded that the country had accomplished a strong legal dispensation and policy framework for enabling the development of a high-quality health system to generate good health outcomes and has seen political commitment to these ideals.4 These include the NHA of 2003, which was amended in 2013 to create the OHSC as an independent regulator to monitor compliance with national norms and standards, promulgated by the Minister of Health in 2017, in both public and private health establishments (HEs).8 On the downside, the Commission articulated persistent impediments including gaps in ethical leadership, management and governance. The high cost of fraud and corruption to the health system was highlighted, with provincial health departments alone carrying in excess of R40 billion in contingent liabilities in medico-legal claims.9
The report highlighted findings of the Health Market Inquiry (HMI) on failures of governance of the private sector10, as well as findings on weaknesses in governance of the Health Professions Council of South Africa11, the South African Nursing Council12, and challenges in community-led governance structures. The Commission acknowledged the HRH strengths in South Africa, but noted that the sustained HRH crisis has the potential to undermine the achievement of high-quality UHC and recommended the development of a transformative HRH plan.
Enhancing governance and leadership at all levels of the health system to achieve quality and equity ranked the highest of the four overarching recommendations of the Commission. Specifically, this meant preventing fraud and corruption, strengthening community health governance structures, investing in and enhancing the capacity of the OHSC, enhancing the capacity and effectiveness of the Council for Medical Schemes (CMS) and strengthening the governance, effectiveness and efficiency of health professions councils.
Policy and planning developments
The commitment to institutionalise quality health systems, characterised by effective governance and appropriate management, remains enshrined in key government policy prescripts for the period 2019–2024. The National Development Plan (NDP) 2030 prioritised access to health services and improving the quality of services.13 The Medium-Term Strategic Framework (MTSF), government’s five-year programme for ensuring implementation of the NDP 2030 linked to each electoral cycle, accentuated the need for effective governance of the health system to ensure that systematic milestones are attained towards transforming into a quality health system.14 To achieve this, the MTSF 2019–2024 includes an imperative to develop and implement a National Quality Improvement Plan (NQIP) to ensure that public health facilities meet the requirements for the OHSC certification and NHI accreditation. Very steep goals are set in the MTSF 2019–2024, including targets that 80% of public sector facilities should implement the NQIP by 2022/23, and this should improve to 100% by 2024.14
Other MTSF 2019–2024 quality-related requisites are that the health sector’s Ideal Clinic Realisation and Maintenance Programme (ICRM), which by 2018/19 had successfully transformed 1 920 Primary Health Care (PHC) facilities into Ideal Clinics, should increase to 3 467 PHC facilities by 2024.15,16 The health sector was also
required to finalise and implement the HRH Strategy 2030, and HRH Plan for 2020/21–2024/25 to enhance existing capacity to deliver quality health care, through provision of adequate numbers of appropriately skilled and competent health workers, with the right attitudes to patients. A comprehensive policy and legislative framework were also to be developed to mitigate the risks related to medical litigation in order to reduce contingent liability of medico-legal cases by 80% (under R18 billion) by 2024.9
The emphasis placed by the MTSF 2019–2024 on a quality health system is consistent with other health sector policy documents, including the NHI Policy of June 2017 and the NHI Bill 2019.2,17
Implementation of improved governance
Progress towards better governance of a quality health system reflects a mixed bag consisting of a modicum of successes and a larger magnitude of impediments.
i) Fighting Corruption
The implementation of the Medico-legal Intervention project through four contracted service providers resulted in a reduction of the contingent liabilities by R32 billion through the identification of cases for forensic investigations, and deceased claimants and fraudulent cases. A Health Sector Anti-Corruption Forum (HSACF) was launched in October 2019 following the signing of the Presidential Health Compact which mandated government and social partners to work together to reform the health care system. The HSACF, comprising various stakeholders and convened by the Special Investigating Unit, successfully dealt with at least 20 allegations of serious maladministration, fraud and corruption in 2020, providing an effective model of a multisectoral collaboration to address fraud and corruption in the health sector.
ii) Office of Health Standards Compliance (OHSC)
As a regulatory entity, the OHSC has a legislative obligation to monitor and assess whether all HEs in South Africa are consistently implementing health norms and standards to assure patients’ health, rights and safety.8 The Health Ombud, currently located within the OHSC, also has a mandate to manage complaints related to the quality of health care from the public and media.8 The OHSC functions under the oversight of a board appointed by the Minister of Health. Ongoing governance challenges faced by the OHSC include inadequate resourcing relative to the scope of its mandate and a perception of lacking true independence from government.
iii) Human Resources for Health (HRH) Plan
The health sector produced an HRH Strategy 2030, and an HRH Plan 2020/21–2024/25 by October 2020 which was approved by the National Health Council.18 This is discussed further in Chapter 17.
iv) Private sector
The Council for Medical Schemes (CMS) as a statutory body established by the Medical Schemes Act (131 of 1998) (MSA) regulates the 78 medical schemes registered in South Africa.19 The governance of the Council is vested in a board appointed by the Minister of Health. The CMS’s report provided a constructive response to governance concerns raised by the HMI and the Commission and is summarised in Box 1.
v) Health Professions Councils
The statutory health professional councils are responsible for licensing of health professionals against prespecified standards, thus ensuring that health workers have the required knowledge and competencies to provide quality health care.20,21 The Commission recommended that the health professionals councils fulfil their legislated mandates for HRH to support the delivery of quality health care by setting appropriate requirements for pre-service training, in-service training and continuous professional development in quality of health care and ethical behaviour for health professionals; and ensuring accountability of health professionals for unethical behaviour. The 2020 HRH strategy specified goals and objectives for improved governance of HRH, including the revitalisation of the HRH regulatory structures to enhance the education, performance and accountability of the health workforce.18 This is discussed further in Chapter 17.
vi) Community participation in governance
The NHA 2003 provides for governance structures to be established for all public health establishments, including clinics, community health centres and hospitals, as well as for the establishment of district health councils.22,23 It was envisaged that these governance structures would contribute to monitoring the quality of health care, and ensuring transparency, accountability and responsiveness to communities. However, they remain an area of weakness in the health system, as demonstrated in a 2017 national survey which found that only 17.9% of clinic facilities had functional clinical committees.24
vii) Development and adoption of a National Quality Improvement Plan (NQIP)
The MTSF 2019–2024 set goals to develop and implement an NQIP in response to the Commission’s recommendations.14 An NQIP was adopted for implementation by the NDoH in 2019.25 Implementation has however been slow, with little uptake by provinces.
The period since 2019 has thus seen a further consolidation of policy and plans which support quality health systems. However, progress towards implementation of these plans has been slow, raising concerns about the engagement with implementing stakeholders in the policy development process. Efforts to address corruption have been made though the problems persist. The responsiveness of the health profession councils remains a concern, and community participation in governance remains weak and ineffectual.
Box 1: Case Study of the Council for Medical Schemes (CMS) response to the Commission
A summary of the CMS response to seven specific recommendations of the Commission4: -
1. Implementation of the provisions of the Medical Schemes Act (as amended)19
The CMS has been implementing the provisions of the MSA 131 of 1998 through its various regulatory activities, and contributed substantially to identifying legislative shortfalls in the MSA and its regulations and to the draft amendments to the MSA published in 2018, currently pending the finalisation of the NHI Bill.
2. Protection of member interests
The protection of member interest forms a key element of the legislated mandate of the CMS. CMS’s performance of relevant regulatory activities, reported on a monthly, quarterly and annual basis, have been relatively successful and are reported in the Annual CMS and Industry Reports.
3. Creation of a dedicated data and quality unit
The creation of a dedicated data and quality unit at the CMS has not been possible due to uncertainty with respect to this mandate, and a lack of resources. CMS’s funding model through member levies is a limiting factor, but ways to increase annual revenues are being explored to support the establishment of this unit.
4. Ensure reporting on measures to improve quality
The CMS has made progress in collecting information to measure the quality of the health services funded through the medical schemes. Currently, reporting is largely of input data on chronic diseases that are funded in the industry. The next step is to start collecting the process and output data, to provide a better perspective of the health care quality, and to look at these outputs relative to the costs in order to determine the value proposition of health care programmes and services to the scheme members. The CMS has a partnership with Health Quality Assessment (HQA), to ensure that there is one industry report on all key quality elements published annually.
5. Enhance communication to share benchmarks and best practice
The CMS has several publications that are shared with the industry on a regular basis, mainly to inform members about their benefit entitlements under the broad banner of the Prescribed Minimum Benefits (PMBs). The Annual and Industry reports illustrate the industry trends on key measures and best practice.
6. Encouragement of an open, learning culture and voluntary compliance
The CMS undertook a roadshow in 2018 and 2019 and visited all the entities that it regulates to promote compliance with the CMS’s regulatory directive. The CMS also embarked on a process to coordinate all industry efforts aimed at combatting Fraud, Waste and Abuse, resulting in (a) Industry agreements on definitions of Fraud, Waste and Abuse; (b) an Industry Charter on Fraud, Waste and Abuse, and (c) Codes of Good Practice for schemes, scheme members, service providers and regulators on Fraud, Waste and Abuse as well as the dispute resolution Tribunal.
7. NDoH ensuring that CMS governing body executes its mandate
The Minister of Health has appointed the members of the governing body, and the most recent assessment indicated that the Council was executing the mandate that they had been appointed to do.
Source: CMS feedback report on the SA Lancet Commission Recommendations, 2 April 2021
Revolutionising quality of care
The Commission reported high levels of preventable morbidity a nd mortality which were associated with poor quality of care in South Africa.4 Gains in immunisation coverage and the establishment of the largest antiretroviral therapy (ART) programme in the world had contributed to a substantial decline in mortality in adults, in under-fives and in pregnant women. However, around 60% of institutional maternal deaths were potentially preventable, and excess neonatal deaths were associated with health system and provider failings. Gaps in ART care quality were identified as inadequate coverage of children, and poor retention in care of all age groups. Underdiagnosis and poor control of chronic diseases such as diabetes, hypertension and mental health as a result of poor access to and quality of care, further contributed to high levels of preventable morbidity and mortality. These findings highlighted the need for a radical transformation of the approach to quality of health care in South Africa.
A critical step was the establishment of the OHSC and its norms and standards, to serve as a national quality control system by monitoring compliance and patient safety at health establishments. The OHSC had, however, conducted a limited number of inspections of public health establishments and none of private health establishments. Findings of these inspections reflected poor performance scores for quality of care at public health facilities across all provinces (OHSC 2014/15 – 2016/17). The Commission identified a compelling need to capacitate the OHSC to allow expansion of inspections in both the public and private sector.4
The Commission also recognised the gains made by the Operation Phakisa ICRM Programme established in 2014 to address deficiencies in the quality of PHC services as described in Chapter 4. This QA programme facilitated monitoring and improvements in quality of care in public sector PHC facilities16, and was adapted for extension to public sector hospitals as the Ideal Hospital Realisation and Maintenance Programme (IHRM).
Several private health care groups and facilities had participated in voluntary health care facility accreditation programmes such as ISO (International Standards Organisation) and the not-for-profit Council for Health Service Accreditation of Southern Africa (COHSASA), the only ISQua (International Society for Quality in Health Care) recognised accreditor of public and private health establishments in South and Southern Africa. The Commission recognised the critical role of these quality assurance (QA) programmes in assessing quality of care against standards for certification or accreditation. The overall impact of these QA programmes on health outcomes was however not clear. An evaluation of the ICRM found significant improvements of health facility scores against the ICRM standards, but not in overall PHC quality outcome measures.26 Systematic reviews of hospital accreditation also found improvements in achieving QA standards, but limited evidence that accreditation improved broader quality or health outcomes.28,29
The Commission identified a wide range of innovative QI projects delivered by government, NGOs, academic and research institutions, the private sector, international partners and funders. These were however fragmented and had limited overall impact, failing to facilitate the implementation of QI across sectors and levels of the health system.4 The Commission recommended that a national integrated, QI Programme of Action be designed in consultation with stakeholders to mainstream QI in the health system.4
The next section reflects on efforts to revolutionise quality of care since the publication of the Commission report.
The Office of Health Standards Compliance (OHSC)
The OHSC undertakes seven key activities with an ultimate goal of improving health service outcomes, as reflected in Figure 13.3
Provinces have largely complied with the submissions of Annual Returns for HEs (Figure 13.4), which are considered alongside reports from the Early Warning System (EWS), an electronic safety and quality surveillance system implemented in public sector clinics and hospitals in 2018/2019. The EWS monitors 11 indicators where there is an immediate risk to safety and quality in HEs to facilitate a rapid response.
13.4 Annual returns submissions by hospitals in South Africa’s provinces in 2019/20
Figure 13.3 The OHSC value chain
Figure
The planned incremental expansion of OHSC inspections from public sector PHC services, followed by district hospitals, referral provincial and tertiary hospitals before being extended to the private sector has however not been realised. A notable decline in the number of annual inspections undertaken by the OHSC since 2016/17 has been attributed to budgetary constraints31 (see Figure 13.5).
The HE inspection findings revealed low levels of compliance with the norms and standards, with less than 20% of HEs meeting compliance levels.32 Leadership and governance, patient safety and security counted amongst the lowest in performance.32,33 To date, no certificates of compliance have been issued, nor any enforcement actions undertaken, but Compliance Notices have been issued.
The NHI Bill (No. 42598 of 26 July 2019) requires HEs to provide proof of certification by the OHSC to be accredited with the proposed NHI fund, placing further pressure on the OHSC to increase the inspections coverage of public and private health establishments.2 The OHSC currently works on a four-year cycle for inspections and certification, and will therefore have to scale up to approximately 10 000 inspections a year to cover the estimated total of 40 000 HEs within such a four-year cycle. With its current capacity and inspection processes, the OHSC is unlikely to meet this demand for inspections, and drastic changes are needed to its inspection and funding models to achieve its regulatory mandate.
Despite reservations about its independence, prominent investigations by the Health Ombud, in particular the Life Esidimeni investigation into the circumstances surrounding the death of mentally ill patients in Gauteng province, have illustrated the importance of this office in responding to serious failures in quality of care.34
Figure 13.5 The total number of annual inspections by the OHSC per financial year
The Ideal Clinic Realisation and Maintenance (ICRM) Programme
By 2020, a total of 3 368 out of 3 481 (97%) of PHC facilities had conducted ‘status determinations’ using the web-based Ideal Clinic dashboard of 208 elements organised in 10 components, and 1 535 out of 3 481 (44%) of PHC facilities achieved Ideal Status, ranging from 15% in the Northern Cape and 21% in the Eastern Cape to 75% in KwaZulu-Natal and 82% in Gauteng.35 Urban provinces performed better than their more rural counterparts, reflecting ongoing inequities in the quality of PHC across the country. Status determinations using adapted ICRM tools had also been conducted in more than 70% of public sector district, regional, tertiary and specialised hospitals by 2020.
Early lessons from the ICRM included that: i) the worst performing facilities had extensive infrastructure, staff and supply-chain management problems, ii) the absence of a clinic manager correlated with poorer performance, and iii) peer reviews functioned well as learning opportunities.36 Responses included the development of a ‘blueprint’ for PHC facility infrastructure to guide the refurbishment of or building of new PHC facilities; the use of national Workload Indicators of Staffing Needs (WISN) and PHC staff normative guidelines to prioritise the filling of vacant posts, particularly clinic managers; and the establishment of a national supply chain management forum.36
A National Health Quality Improvement Plan (NQIP)
The NQIP, adopted at a Presidential Health Summit in December 2018, set a five-year goal to prepare health facilities for OHSC certification and NHI accreditation.25 A key element of this plan was the establishment of four Quality Learning Centres (QLCs) in each province as focal points of learning and capacity development in QA and QI. Each QLC would include a regional, district and private hospital, three PHC facilities, family practitioners, and emergency medical services to facilitate shared learning across multidisciplinary teams. By 2021 a total of 16 QLCs had been identified, consisting of 80 hospitals and 64 PHC facilities, a fraction (1.85%) of the 3 467 public PHC facilities in South Africa.
The slow uptake of the NQIP could be partially attributed to the COVID-19 pandemic. However, it was also critiqued as ‘vague’, out of sync with QI principles and approaches, and failing to clarify how it addresses gaps in, strengthens or complements the ICRM programme.37 The NQIP may have benefited from broader stakeholder engagement, particularly from frontline health care providers and QI experts and practitioners.
Quality Improvement (QI) Projects
Most QI initiatives have focused on priority diseases and programmes such as Maternal and Child Health (MCH), HIV and tuberculosis (TB), and have been developed and implemented with external partners such as the Institute for Health Improvement (IHI), CDC and USAID and external funders. A range of QI approaches including the IHI Improvement model and Quality improvement collaboratives, Lean Management, Six sigma, and Kaizen have been applied across projects. One such MCH QI project, the Mphatlalatsane (‘the first star before dawn’ in Setswana) Project, has provided important lessons for applying QI in South Africa, and is described in a case study below.
In 2018 the NDoH, with the Clinton Health Access Initiative (CHAI) and other partners, launched the Mphatlalatsane Project for Quality Improvement in Sexual, Reproductive, Maternal and Neonatal Health to improve the quality of health care to reduce maternal and neonatal mortality by 50% by 2022.
The project used the IHI Model for Improvement (MFI)38 following three steps of i) setting project aims for improvement; ii) selecting measures to determine if improvement occurs; and iii) testing if self-identified strategies change the existing process and result in changes in outcomes39. QI advisors support local QI teams across the three steps, and continuous improvement is effected through Deming’s Plan-Do-Study-Act (PDSA) cycle40 (see Figure 13.6).
Figure 13.6 PDSA Model for Improvement
Each change idea is tested on a small scale at facility level, and then iteratively over a few weeks by increasing the scale and reach until significant change is evident in the data. Run charts are used as a tool to monitor progress and measure change. We describe one of the case studies below.
Case Study: Hospital – Labour and Delivery: Triaging of labour ward patients in Themba Hospital in the Ehlanzeni District
Themba Hospital, a regional hospital which performs a large number of monthly deliveries (N=675), reported an increase in the number of birth asphyxia cases, contributing to acute complications and morbidity in infants.42 A root cause analysis suggested that pregnant women in Themba Hospital were only seen when already in advanced labour. The hospital had no standard triaging system nor any triaging space. Labour complications were not addressed in time because of poor monitoring during the first stage of labour. The aim was to triage 80% of pregnant women admitted to the labour ward from a baseline of 0%.
Intervention: A triage stamp was designed, and an admission midwife or doctor assigned to the admission room daily to manage the triaging process. One bed in the admission room was allocated for triaging. The admission register was redesigned to indicate arrival, triage, and admission time to assess progress and to check if the changes implemented were effective.
Results: Triaging improved from 0% to 90% until March 2020 when a COVID-19 pandemic hard lockdown was introduced (see Figure 13.7).
Figure 13.7 Themba hospital percentage of patients triaged within 10 minutes of arrival within the maternity admission room (Source: CHAI South Africa Team: Degratia Masenya, Azukile Nzuzo, Sunette Pienaar, Daniel Nhemachena and Yogan Pillay, 2021)
There was a noted reduction in birth asphyxia cases between July and September 2019 (N=14) and the same period in 2020 (N=3). The decline in triaging from March 2020 (69%) was attributed to COVID-19 and the resultant staff shortages and increased workload.
Lessons learned: The following lessons were identified from the case studies:
• Stakeholder engagement, including clinicians at the forefront of patient care as well as patients, is important in QI project implementation and sustainability.39
• A multidisciplinary team approach assists in facilitating change.43 QI projects are collaborative by design, and involving health care workers at all levels contributes to successful implementation.
• ‘Participative innovation’ can be stimulated by creating enabling environments, providing safe spaces, increasing responsibility and acknowledging the efforts of all team members to improve motivation.44
• Staff need competency in clinical skills to implement QI projects.45
• The leadership of senior management is key for the progress and sustainability of QI projects.46
• Reliable data is important to accurately assess performance, to identify problems and to measure progress. QI projects also create an opportunity to improve the quality of data.
The case studies demonstrated the viability of the MFI in maternity and neonatal care at different levels of care. Facilities should consider QI as an integral approach to service delivery rather than as an add-on activity.
eHealth to improve quality
of care
eHealth, defined as the use of Information and Communication Technology (ICT) in health care, includes the use of mobile phone technology (mHealth), computer information systems for data management systems or as clinical decision support systems, and telemedicine or remote care.
An important example is MomConnect, a national digital health initiative which reached 1.5 million pregnant women by 2017, one of the largest mHealth deployments as a proportion of target population in the world47; see also the coverage of this in Chapter 5 on National Health Programmes. Its three main features are: 1) registration of women who are pregnant into a national pregnancy registry, (2) weekly informative text messages, and (3) an interactive help desk for pregnant women and mothers of infants using the public sector. Virtually all (95%) public sector clinics have MomConnect in place, and registrations as a percentage of all antenatal clinic first visit attendees was 64% in 2017.47 User acceptability was very good, with women expressing confidence in the messages received, reporting improved health behaviours and excitement about their role.48 Complaints and feedback from women highlighted health systems quality problems such as shortage of drugs and vaccines, long wait times,47 clinical abuse, and patient neglect by health care professionals.49 Services used this feedback to address quality problems, with the available evidence suggesting that MomConnect has had an overall positive effect on end-users and contributed to a national increase in antenatal clinic visits.50
Private Sector Quality
The Commission reiterated the findings of the HMI on the failures of governance in the private health sector, noting that the NDoH had failed to use ‘existing legislated powers to manage the private health care market, to ensure regular reviews by law, and to hold regulators sufficiently accountable’.10 It also noted the sharp increase in insurance for private medical practitioners associated with a rise in medico-legal claims in the private sector, and reports of nursing malpractice in private hospitals.
The Council for Medical Schemes (CMS)
The CMS has a mandate to advise the Minister of Health on criteria for measurement of quality and outcomes of health services provided by medical schemes, and to collect and disseminate information about private health care.19 The CMS has access to extensive claims data on private sector health care, but has provided limited analysis of quality of health care through medical schemes. The CMS’s annual reports show poor overall compliance by medical schemes with management of chronic diseases, with low rates of testing, screening and preventative interventions, e.g. aspirin in Ischaemic Heart Disease patients. The CMS also reported a rate of caesarean deliveries of 76.9% in the population covered by medical schemes, amongst the highest rates in the world, reflecting inefficient use of health care resources.52
Citing a lack of resources and capacity to fulfil its mandate to collect and disseminate information on the quality of health care in the private sector, the CMS has utilised a partnership with HQA for the purpose of reporting on quality.
Health Quality Assessment (HQA)
HQA is a non-profit company that has been conducting annual quality of care surveys using mainly medical scheme claims paid data for the past 17 years.53 HQA membership includes 18 medical schemes, and 80% of all insured beneficiaries. HQA provides reports to its members and presents industry-level survey results at a Clinical Quality Conference annually. It provides industry-level benchmarks for each of 174, largely input and process quality indicators for chronic diseases that managed health care organisations, schemes and health care providers can use to monitor quality. This currently represents the only source of collated and analysed data on the quality of care across a wide section of the private sector. However, the data is ‘owned’ by the members, and is not accessible in the public domain for policy-makers, funders or service users.
The 2020 HQA report indicates a slow but progressive improvement in monitoring interventions for high blood pressure, accompanied by a progressive increase in hospital admissions, adjusted for age, gender and chronic disease, for stroke.
Other private quality of care initiatives
Private sector hospital groups are increasingly measuring quality of care and adopting QA and QI processes. Reports of QA and accreditation of private health establishments through COHSASA or ISO are however not available in the public domain. Examples of QI within private hospital groups include the use of IHI’s Triple Aim methodology (best patient experience, best outcomes, and cost effectiveness), and QI for reducing hospital-acquired infections through implementation of care bundles (‘Better Care Always’), hand hygiene programmes, and antimicrobial stewardship.54
The Hospital Association of South Africa (HASA), representing the private hospital sector, commissioned research on the measurement and reporting of quality of care by hospitals in South Africa. The report made recommendations to ensure a fair and effective quality measurement framework and provided a sample set of indicators for private hospitals, including measures of performance outcomes, as well as process measures.55,56
The Board of Healthcare Funders, a representative body for health care funders, developed and piloted an ‘Effective Coverage’ monitoring tool to enable medical schemes to measure the extent to which an at-risk population receives key interventions and remains free of adverse outcomes in preparation for UHC.57,60
Measurement of quality
The Commission advised that a high-quality health system requires accurate, reliable and timely health information. It found an enabling environment for health information systems (HIS) created through a longstanding commitment to measuring quality expressed in various health policy documents. However, numerous shortcomings included that HIS were only partially electronic, lacked patient-level data, and were fragmented systems incapable of reporting aggregated data across levels of care or care pathways, or across public and private sectors. The South African HIS also focussed largely on input and process measures, with insufficient reporting of outcomes and impacts. Data quality remained a concern, and utilisation of the data by health care professionals and managers was sub-optimal.4
Recommendations included defining national performance targets which measure quality outcomes; and prioritisation of a process of analysis, interpretation and feedback of key indicators. The Commission also recommended strengthening the stewardship role of the national HIS of South Africa.4
Very little has changed in the state of HIS since the publication of the Commission’s Report. Of note is that the initial separate and parallel developments of the OHSC and the IHF programmes, which contributed to an overwhelming volume of audit processes at health facilities, data collection and information systems, have since been aligned to improve efficiency and reduce the reporting burden on health facilities.26,59 Remaining challenges include the ongoing emphasis on input and process measures, with insufficient assessment of quality of care outcomes and impacts, and a lack of transparency of information, with public reporting of quality of care only occurring at an aggregate level, with limited access to the information by clients and communities served by health establishments.
The OHSC measures have not been formally applied to the private sector yet. The HQA and CMS quality of care reports at medical scheme and managed care levels remain largely limited to input and process measures for chronic diseases and are not publicly available.
Although HASA reported that private hospitals have the capacity to measure aspects of quality, and that many are, there does not seem to be any aggregated data at private hospital and clinic level. Private hospitals measure quality largely for internal processes, while some share information within and across groups, or share results at the individual hospital level with funders. The main focus has been on value for money, based largely on input, process and output measures with little assessment or reporting of outcomes of clinical care. The distinct approaches have not been designed to enable comparability across the sector.56
Within primary care in the private sector, the need to improve the quality of health care in relation to the cost of fee for service has prompted the development of a plethora of performance tools to hold providers accountable for the quality of health care delivered. However, there is no uniformity in methodology, data collection, analysis and interpretation of results, and clinicians are adjudged to be at different levels of ‘quality’ by different funders.
Conclusions and way forward
The South African National Lancet Commission on Health Systems Quality reported some achievements and numerous challenges to the delivery of quality health care, with clear recommendations to achieve a quality health system for South Africa. Important early gains have been made since, but several key actions have stalled.
National plans were finalised, and actions initiated to reduce and manage fraud, corruption and the cost of medical malpractice; to address the HRH crisis; to support QA and QI; and for the expansion of the ICRM programme into public sector hospitals. The OHCS and the IHF made progress in aligning information systems, and almost 50% of PHC facilities achieved Ideal Clinic status. Innovative QI projects for priority health programmes provided valuable lessons from the field, and the use of ICTs created innovative ways of supporting quality of care. In the private sector, the CMS responded constructively to the Commission’s recommendations with intentions to assess and report on quality of care.
The COVID-19 pandemic contributed to delays in the implementation of plans for quality of care, in particular the HRH plan and the NQIP. The OHSC struggled to meet a mandate beyond its resource capacity using a model for inspections and certification which appeared neither efficient nor effective. Fraud and corruption continued to plague the health sector, particularly with respect to COVID-19 supplies and services. No apparent responses were forthcoming from health professions councils, nor processes to strengthen community engagement with quality of care. Although the CMS and other private health sector stakeholders demonstrated a willingness to assess and improve the quality of care, this has not translated into sector-wide plans or actions. The COVID-19 pandemic further exposed weakness in health systems quality in areas such as supply chain management, infection prevention control and occupational health. The higher excess deaths during the COVID-19 pandemic in provinces such as the Eastern Cape, Northern Cape, KwaZulu-Natal and Free State further demonstrated inequities in the quality of health care across the country.60
What is to be done?
Looking ahead, sustained and effective governance and leadership is essential for the attainment of quality health systems in South Africa. Governance should not only focus on the development of legal and policy frameworks for improving quality, but should establish collaborative processes and strengthen management to better coordinate and support implementation across sectors and levels of the health system.61 There is an urgent need for leadership and stewardship from government, the various health regulatory bodies and private sector leadership to drive QA and QI in the public and private health sectors to achieve the desired UHC objective by 2030. The key milestones attained towards reducing medico-legal claims in 2021/22 should be sustained. It is also imperative for the health sector to rebuild, revive and strengthen structures for community participation in governance of quality of care, particularly hospital boards, clinic committees and ward health committees.
The OHSC needs to review and extensively revise its funding and operational models if it is to achieve its regulatory mandate and meet the NHI requirements. At a national level, greater emphasis should be placed on assessing fewer measures, refocusing on outcomes of quality to better assess actual performance, with less emphasis on national reporting of inputs and processes. Health districts, sub-districts and health facilities should be empowered to monitor inputs and processes which are relevant and meaningful to frontline providers to improve the quality of care. There is little evidence to date that the extensive national quality control processes are able to improve the quality of care in the absence of a strong groundswell of district and facility-based quality improvement.
Although the ICRM is being successfully expanded, frontline health managers felt excluded from the planning and not in control of quality aspects that they were held accountable for, often leading to ‘malicious’ compliance which undermined the objectives of the ICRM.62 Greater efforts are needed to involve frontline health managers in the planning and implementation of QA and QI systems, to strengthen their capacity and expand their ‘decision space’ to enable them to respond to gaps in quality.62
The lack of transparency and access to information on quality of care in both the public and private sectors, with insufficient feedback to providers and communities, is a further impediment to initiatives to improve the quality of care. Evidence shows that disclosing information to the public about hospital quality of care encourages hospitals to implement QI strategies.63 Within the private sector, reducing information asymmetry, i.e. the lack of information available to health care consumers (i.e., patients), but which applies also to institutional purchasers (e.g., medical schemes), is seen as a mechanism that advances quality through the effects of improved market functioning.56 PHC initiatives such as the Ritshidze community-led monitoring and evaluation of HIV care are also demonstrating that access to locally relevant information can support improvements in quality of care.64
In conclusion, some progress has been made to ‘revolutionise quality’, but overall implementation of the Commission’s recommendations has been limited. The proposed plan of action for improving the quality of care was not achieved through the current top-down version of an NQIP. There remains a need for an overarching national QI strategy which engages all stakeholders, including frontline health workers, civil society and the many current quality of care players who operate within separate health programmes or sectors. Such a strategy should build on the extensive experience and expertise in QA and QI in South Africa to support efforts to improve the quality of care across sectors and levels of care. More transparency and communication of the state of quality of care in the public and private sectors can contribute to stimulating QI initiatives. Finally, failures in governance and leadership by key partners need to be addressed.
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