OHSC – need we help it to do more?

The hills are where the homes are for the communities in this part of the Wildcoast. The remoteness means that health services are sketchy at best, making home visits by caregivers a critical part of making sure people don’t fall through the cracks

The Rural Health Advocacy Project’s Samantha Khan-Gillmore makes a impassioned plea for the Office of Health Standards Compliance to be capacitated to do more.

In the early hours of the morning in January 2017, two young, energetic, men were involved in a serious collision and were immediately taken by ambulance to the nearest health facility for emergency treatment in Bizana, Eastern Cape. Between the two men, they had sustained head injuries, a broken jaw, shoulder, ribs and arm, a badly lacerated tongue, severe bruising and other cuts and abrasions. Eighteen hours after arrival at the facility they were yet to be seen by a health professional. No x-rays were done. No wounds were cleaned. No injuries were addressed. No medical care was given to either of them.

Shortly after the accident and upon arrival at the facility, a family member, Mr Mthethwa* was advised that the injured relatives would have to wait to be transferred to the nearest orthopaedic hospital in the Eastern Cape before they could receive much needed medical treatment.

Thirty-six (36) hours after the accident, the hospital staff informed the family that they could not be transferred to the next referral hospital until the following Wednesday – some five days after the accident. Mr Mthethwa took the decision to remove his family from the hospital’s care and personally transported them to a hospital in Durban where they finally received medical assistance.

Due to the delayed treatment, both young men do not have the full use of their arms, are undergoing intensive rehabilitative care and are no longer employable in their current positions which requires heavy lifting duties. One of the two young men is also now receiving a disability grant due to the injuries that do not allow him to secure full-time employment.

Persuant to the treatment of the young men at the hospital, Mr Mthethwa decided to approach the Office of Health Standards Compliance (OHSC) seeking recourse for what happened to his family. The introduction of the OHSC (through the National Health Amendment Act of 2013) is a great step towards health equity for patients and the health system as a whole because it is a regulator of quality healthcare for all. One of its core functions is to objectively assess the performance of health facilities towards the attainment of quality healthcare. In line with its mandate, the OHSC investigates complaints relating to breaches of prescribed norms and standards. The vision of the OHSC is “Safe and Quality Healthcare for all South Africans”

The hospital referred to in the complaint above is in the Alfred Nzo District of the Eastern Cape. Alfred Nzo District has a  population of 843 294 and a population density of 78.6 people per km2. The district comprises Maluti and uMzimvubu health sub-districts and falls within socio-economic Quintile 1, among the poorest districts in the country, according to the District Health Barometer 2016-2017. The health statistics are indicative of the Quintile 1 status. Less than 3% of households have piped water and less than 5% have flush toilets. Children under the age of five are prone to diarrhoea, which is often linked to poor sanitation and lack of clean water. Malnutrition in pre-school children is rife. With the publication of the District Health Barometer annually, Alfred Nzo consistently performs dismally with very poor health outcome indicators. Alfred Nzo has the lowest primary healthcare expenditure per capita for 2016/17 of all districts in the country at R617. The same district was also the lowest at R599 for 2015/16. It is evident that the Inverse Care Law is still very much alive – those most in need have the least available resources.

The main objectives of the OHSC are to protect and promote the health and safety of users. This may be a noble undertaking and despite the OHSC being a much needed intervention, it does not yet have the internal capacity to deal with the numerous challenges across the country. In the 2015/16 reporting period, the OHSC received 73 complaints. This has escalated to 1122 reports in the 2017/18 period. This increase could be due in part to the #LifeEsidimeni case but also because the OHSC is gaining traction and publicity through its National Core Standards which facilities must subscribe to. The volume and scope of complaints is vast and despite attempts to respond to each and every complaint received, this is clearly not possible. According to the OHSC Annual Report 2017/2018, most complaints originated from Gauteng (378) and KwaZulu-Natal (138). The Eastern Cape, the province with at least two of the most deprived districts in the country, lodged 129 complaints.

Mr Mthethwa remembers being at the hospital where his family did not receive treatment in the Eastern Cape. He heard a community member say that the hospital has a reputation in the community of being a place of death for sick people. Another community member says: “we call it the mortuary, because we do not come here for treatment – we come here to die.”

In a meeting in August this year with the OHSC, while acknowledging the pain and distress of the family, the hospital cited staff shortages as the main reason for the lack of treatment on that fateful day. This may be true. Human resources for health are a scarcity in the current health system climate, particularly in the public sector and definitely in rural communities. The question is, are we prioritising the worst-off with our available resources and are we using human resources efficiently? The Clinical Associate profession was introduced into South African tertiary institutions in 2008 through a 3 year Bachelor of Clinical Medical Practice degree. The introduction of the new profession was a way of addressing the continuous and severe shortage of health care workers especially in the public health sector. Clinical associates are qualified to perform many clinical procedures including conducting consultations (history taking and physical examination); ordering and interpreting investigations (lab tests, X-rays) as well as to diagnose and treat common conditions.There are many unemployed clinical associates that are a cost-effective answer to improving access to clinicians particularly in rural and underserved areas. Why are we not utilising these available resources?

This hospital has unfortunately escaped the last three annual audits and inspections of the OHSC (only 700 facilities were inspected between 2016 and 2017) but it is clear that there are significant changes that need to occur for health users to be satisfied with the services received. While the OHSC has been instrumental in highlighting many health system challenges, do we not need to bring in the provincial departments of health to account for how it addresses the OHSC findings?

In dealing with hospitals such as the above, there are a few options available to provincial health departments to mitigate a better health passage for health users and to translate vision into action for deprived communities:

• Prioritise the worst-off
• Bend the rules and accredit facilities that far from meet the national core standards
• Don’t accredit and leave rural communities out of sight and out of mind

Which one will it be? We trust that it will be the first option.

We want to see that facilities serving deprived communities are prioritised in the next phase of the NHI preparations. Soon enough, the excuse of low staff complement and lack of resources will no longer suffice for a population who is witness to daily healthcare challenges.

National and provincial treasury departments should ensure adequate funding provision for the OHSC in order for it to carry out its mandate efficiently and effectively. It is evident that greater powers should be afforded to the OHSC – without it, it remains a complaint tool with little or no executing powers As people living in South Africa, we need a body such as the OHSC, however we need one with not only a bark but a huge bite as well.

*Mthethwa is not his real name