By Ektaa Deochand
2018 was a significant year for the development of health policy. Among others, it saw the ministry of health acknowledging the parlous state of the health system and the need to address systems failures while attempting to achieve universal health coverage through National Health Insurance (NHI).
On 24 August 2018 at a Department of Health stakeholder consultation on NHI, the Draft Quality Improvement Plan (“the NQIP”) was released. On 19 and 20 October 2018, the Presidential Health Summit took place which culminated in a report meant to facilitate the creation of a collective ‘health compact’. These two documents are meant to mark the beginning of a roadmap toward achieving a quality health care system.
The NQIP represents a recognition by the Department of Health that there are deficiencies in the current health system which require the development of a detailed and adequately funded quality improvement plan and guideline. Although this is a welcome recognition, does the NQIP provide a realistically realizable plan in order to do this?
The NQIP appears to be a plan for yet another plan in order to bring all the existing initiatives together, identify those that are working well and review the implementation of those with poor results.
Before the introduction of an improvement plan, there should be a detailed evaluation of existing data and an examination of the state of health care facilities in the country, which appears to be lacking. The Access to Quality Health Care in South Africa Report identified the lack of publicly available comprehensive, accurate data on both the public and private health sectors, as a key constraint to detailed evaluation of efficiency, equity and quality in the South African health system.
The principles of the NQIP are commendable, and at first glance appears to be a standards-and systems-based quality improvement process, focusing on health outcomes by building management and team work capacity and health facility readiness. However, the steps in the plan seem out of sync with these principles.
There are some immediate sensible interventions identified in the NQIP, such as lifting the moratorium on the filling of critical and essential posts. In the 2019 budget review, R2,8-billion from the National Health Insurance Indirect Grant has been reprioritised to the new human resources capacitation grant over the next three years to fill critical posts. R1-billion has also been added to the community outreach services component of the HIV grant for the employment of community health workers, however this will only be allocated in 2021/22.
The Presidential Health Summit Report (“HSR”) similarly recommended that the moratorium be lifted on critical posts and that the policy on remuneration of work outside the public service be reviewed in order to limit impact on service delivery. Some identified medium term actions of the HSR were to validate and optimise the use of the PERSAL and HR management information systems and to review the roles and responsibilities of each sphere of government.
It remains to be seen how these recommendations will be carried through, as there is currently no national applicable human resources strategy document despite the National Health Act requirement that the Minister and National Health Council determine guidelines for provincial departments and district health councils to implement programmes for the appropriate distribution of health care providers and health workers.
The state of many health care facilities results in ever decreasing faith in the health care system. Millions of Rands over many years have been dedicated to infrastructural improvements and maintenance. Despite this, insufficient progress has been made.
The HSR notes that the Department of Health “has a health infrastructure plan but to date the country has had neither the expertise nor adequate funding to implement the plan. In some cases, health infrastructure construction that has been successfully completed has either cost more than the initial budgeted amount or facilities have been constructed that fail to meet the need for the service required.” It also states that in most cases there is insufficient capacity for project implementation, monitoring and evaluation.
The Ideal Clinic Realisation and Maintenance Programme (ICRM) was developed to address deficiencies in the quality of Primary Healthcare Services (PHC). Despite the NQIP asserting that the first two phases are complete and the focus is now on implementation, it is unclear what the progress has been of the ICRM to date nor whether it should be pursued as an effective method of improving quality care. Many clinics which have been identified as ‘ideal’ such as the Philani Clinic in Queenstown remain far from ideal. The infrastructure remains poor, human resources are insufficient, and very little support is provided to the clinic committee. Operation Phakisa was launched in 2014 to scale up the ICRM, but in 2018 clinics only achieved 47% compliance with the assessments conducted by the Office of Health Standards Compliance (OHSC) and only 43% of clinics met the Ideal Clinic Status.
Some recommendations of the Operation Phakisa Ideal Clinic Laboratory were to develop a standard blueprint for the construction of new facilities or existing facilities needing refurbishment; and to develop maintenance hubs in districts to ensure that planned maintenance is carried out. The 2017 Health Review indicated that the NDOH and the provinces were in the process of completing schedules for PHC facilities which need refurbishment. It is unclear what the status of these schedules are nor whether the recommendations of Operation Phakisa were ever implemented.
The HSR recommendation on infrastructure is that there must be an investigation and revision of the ‘national master infrastructure plan’ and that alternative funding mechanisms for infrastructure development be explored. The HSR refers to an assessment conducted in 2015, which states that 20% of the PHC infrastructure requires replacement, and that the data concerning PHC facilities is too inconsistent and poor for detailed planning. Greater transparency is required regarding these assessments, as well as information as to whether any independent assessments have been done.
Over the next three years R19,2-billion has been allocated to the health facility revitalisation grant and a further R4,3-billion has been allocated to the health facility revitalization component of the NHI indirect grant. This is meant to fund 1 500 infrastructure projects, including new facilities, upgrades, refurbishments and maintenance. Additional allocations have been added to fund the new academic hospital in Polokwane. However, in order for provinces to access this grant a two-year planning process is needed in which provinces are assessed and required to obtain a minimum score of 60% in order to qualify for the incentive. Only three provinces qualified in the 2019/20 financial year (KwaZulu-Natal, Eastern Cape and Western Cape).
Certification by the OHSC
The arduous certification/accreditation process in terms of the NQIP brings more questions than answers to light. It states that “it is a requirement that all health facilities designated for NHI meet the quality standards set by the Office of Health Standards Compliance. Thereafter, 25% of facilities will need to achieve accreditation as set out in the draft NHI Bill within a year.”
Certification by the OHSC requires an OHSC that is adequately capacitated in order to effectively measure and enforce compliance with the Norms and Standards Regulations Applicable to Different Categories of Health Establishments (which came into effect on 2 February 2019). The 2016/2017 Annual Inspection Report of the OHSC shows that in that financial year, only 17% of health establishments were inspected. The OHSC budget allocation has only increased by 5.5% this financial year, and its total staff complement is expected to remain at 121. Based on its existing capacity and budgetary constraints, unless there are serious adjustments in budgetary allocations, the OHSC will not be able to inspect all the public health establishments to assess compliance.
Accreditation for the purposes of contracting with the NHI Fund
There are additional criteria listed in the NHI Bill for facility accreditation by the NHI Fund, such as provision of the minimum required range of services; allocation of the appropriate number and mix of healthcare professionals; adherence to treatment protocols and referral networks and submission of information to the National Health Information Repository and Data System.
To make matters even more complicated, the NQIP identifies four levels of achievement within the NHI accreditation process, where only facilities with full compliance will be permitted to provide the complete range of services offered in the NHI.
Whilst private and possibly some public facilities may meet the full compliance criteria, it is unclear how communities currently served only by public facilities would have access to health care services if these facilities failed to meet the accreditation criteria. This risks a reduction in access to services and a regression in realisation of the right to access health care services. Potentially it could mean that people with access to poor quality services now end up with access to no services at all as facilities may not be accredited and therefore not funded. The process for bringing non-compliant facilities to a state of compliance is not provided for in the NQIP.
Governance, Management and Leadership
With regard to governance and management, the NQIP states that there needs to be a wholesale transformation of the management system with decentralization to hospital managers, however it fails to provide details as to how the capacitation of this level of leadership will be carried out.
The HSR identified that there has been poor implementation of governance policies and that there is a need to address political interference in management processes. It states that politicians must have oversight but not get involved in the administrative execution of policies, but does not provide further details as to how this will be monitored. It does however recommend the creation of an anti-corruption forum for the health care sector, which has commendably, recently been established by the Special Investigating Unit.
The HSR further proposes that clinic committees and hospital boards be capacitated according to standardized guidelines. Currently only four provinces have passed legislation or policies relating to the regulation of these committees, and even where committees do exist, they are seldom supported by district health management to effectively fulfil their role.
The NQIP is mainly silent on financial management or resource allocations. The HSR however, discusses a ministerial task team investigation into the financial conditions at public hospitals. It found similar issues in all provinces as a result of over expenditure and accruals. It recommended that provincial treasuries be engaged on the baseline allocations with priority given to rural communities. The HSR proposed interventions include; reduction of accruals and understanding the cost drivers; limiting the role of conditional grants as a core resource allocation mechanism and assessing inefficiency created by restricted conditionalities; revisiting the equitable share formula; reconsideration of the human resource mix; addressing bloated management structures focusing on staffing service delivery; creating incentives for better revenue collection; and revising the tariff structure.
The NQIP is the answer meant to alleviate the concerns raised around NHI. Whilst it demonstrates strong principles and optimistic ideals, the practicality of the plan remains muddled in the mix of health compact processes. The NQIP alone is insufficient in its current form to address the major system flaws of the public health sector. The HSR sheds some frightening light on the broader issues, and as such, a much more detailed consolidated pathway and reprioritisation of budgets will be required in order to address the compounding issues relating to human resources, infrastructure, and governance if these plans are ever to translate into concrete change.
Deochand is an attorney at SECTION27.