Fixing the ailing public health system requires us to go back to basics

by Anton Stoltz: Currently heads the division of infectious diseases at University of Pretoria. He is an Infectious Diseases subspecialist trained in the management of patients with MDR and XDR tuberculosis co-infected with HIV.
by Gustaaf Wolvaardt: A qualified medical doctor, a specialist in Internal Medicine and Managing Director of the Foundation for Professional Development.
Health indicators such as life expectancy are a barometer of progress in a country. Improvement in health follows sustainable economic and social prosperity. Traditionally as countries emerged from poverty their disease burden shifted from infectious diseases to chronic diseases of lifestyle. Unfortunately this is no longer the case as infectious diseases are constantly emerging and re-emerging and are a major threat not only to life but also to socio-economic development.

Globally there is a major concern around outbreaks of resistance organisms, driven by factors such as inappropriate legislation, war and social deprivation. Large cross border migration, especially in Africa, often results in poverty, famine and outbreaks of infectious diseases. Worldwide an infectious disease crisis is looming, threatening to diminish hard-won gains in health and life expectancy. Rapid increases in intercontinental air travel transports infections from country to country leaving no country safe from any outbreak anywhere in the world. Critically this is happening during an upsurge in drug resistance across the globe.

Six diseases make up over 90% of all deaths due to infectious diseases. HIV/AIDS, tuberculosis, pneumonia, diarrhoeal diseases, measles and malaria are the infectious diseases that overwhelm health care systems and are the biggest drivers of health care cost. All of the above are preventable and herein lay the principles in fixing our infectious diseases problem. Infection prevention and control rests on four pillars namely; managerial control, administrative controls, environmental controls and personal protection control. Containing outbreaks of infectious diseases when they occur depends on rapid response by health care authorities and targeted health education to ensure the safety of individual lives. This requires a well functional health care system.

Addressing the major challenge around fixing the ailing health care system will also translate into an improved ability to respond to emerging and reemerging infectious diseases.

The health care system of a country comprises all sectors both private (for-profit and not-for-profit) and the public sector. Key to improving the ailing health care system in South Africa is creating greater integration between the public and the private health care system. Currently the private sector is expensive and has an over concentration of health care professionals while the public sector is faced with an increasing disease burden, an increasing patient load and limited resources both financial and human. The envisaged National Health Insurance is the most critical reform envisaged to create better integration between the two systems and depending on how it is implemented will increase the percentage of the population that will be able to financially contribute towards their own health care through compulsory payroll taxes, will create better distribution of patients between providers allowing more patients to access private providers and will hopefully through competition improve the quality of care offered by public sector providers.

Professionalising health care management in the public sector will be a further key success factor. A recent audit done of management competency at public sector hospitals has highlighted the lack of managers with management qualifications and the requisite competencies. The Minister of Health has made a commitment to ensuring that all managers are appropriately qualified. This commitment now needs to translate to action; health care managers should be required to acquire the necessary qualifications rapidly or be replaced with competent managers. Ensuring adequate qualifications will be a first step towards fixing managerial and administrative controls although it should be kept in mind that qualifications do not automatically translate into competency.

The administrative controls lay down the rules by which the health care system should operate. Such controls extend beyond management of health care services The creation of national consensus-treatment guidelines to harmonise treatment regimes in both the private and public sector are essential in ensuring sustainable and optimal care. Examples exist in Sweden and Scotland for the setting of these guidelines and its implementation. They are set as countrywide standards of median care, free from pre-determining monetary- or other vested interests. RSA currently only has such guidelines for the 25 chronic conditions under the Medical Schemes Act. An urgent need exists to expand these guidelines to all major conditions and especially for infectious diseases through a national consensus exercise to reverse the current fragmentation of services into upper and lower “class” health care and into a separate set of standards for state- and a different set for private care.

Key to the management of all chronic conditions and especially infectious diseases such as HIV/AIDS and Tuberculosis is the ability to ensure continuation of treatment irrespective of the movement of patients around the country. In a country such as South Africa with a large migrant labour force this need is critical. In the light of this, the establishing of a functional national health information system encompassing a common IT platform for users, providers and facilities in both the private and public sector will be another key requirement to fixing the ailing health care system. Such a system should form the basis of the National Health Insurance system and be accessible from all points of health care service delivery irrespective of being in the public of private sector. A common electronic medical record with appropriate standards for data-collection, privacy-protection and data-use will allow seamless continuation of treatment as patients move between health care facilities and will greatly reduce wastage linked to duplication of laboratory and other special investigations.

Pivotal to rebuilding the health care system is the need for ensuring that the country has sufficient health care professionals to meet the need of an expanding population and an increasing disease burden. There is an acute need for a rational human resources in health strategy that needs to be fully costed and funded. The country is running out of skilled health care professionals. Production of medical doctors has been stagnant since the mid 1980’s with around 1200 graduating annually while retention has been poor due to increased emigration and natural attrition. The International Organisation for Migration estimates that South Africa annually loses around 1000 medical practitioners through emigration, retirement and death. Adding to this shortage is the high prevalence rates of HIV in some of the professional categories such as nursing where production has dropped alarmingly with the exception of the private sector. There is a need for an urgent focus on increased production across the board and consideration should be given to the potential role private higher education institutions can play to increase the number of health care professionals being produced, linked in the short to medium term to a sensible policy to supplement key shortages through foreign recruitment.

Quality of care should not be a negotiable in either the private or public sector. The recent establishment by the Ministry of Health of an independent office for quality standards is certainly a step in the right direction and would be strengthened through a toll free line for patient complaints monitored by an ombudsman.

In the final analysis irrespective of how well the health care system functions, the largest impact of disease burden is through modifying the environment in which diseases develop. Environmental control must take place at household and community level and is directly linked to economic and educational levels in the community. Without concerted effort to stimulate economic and educational development that will translate into better housing, water and access to food, we will face an uphill struggle.

In the final analysis the best hope in reforming an ailing health care system is ordinary South Africans, who have the necessary education to understand disease risk and how to mitigate such risks. Have the knowledge to access prevention services, such as vaccination services, and most importantly the confidence to demand quality of care for them and their children.
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