A basic introduction
Kerry Cullinan
Health-e News Service
January 2006
Table of contents
Context
Primary Health Care
– Background
– Norms and standards
Hospital services
– Background
– Levels of hospitals
– District hospitals (level1)
– Regional hospitals (level 2)
– Tertiary hospitals (Level 3)
Alarm bells
Conclusion
References
Appendix 1: Patients’ Charter
Appendix 2: List of the content of district hospital package prepared by the national PHC task team
Introduction
There is a widespread perception that services in hospitals have seriously deteriorated over the past few years, due in large part to staff shortages and the growing HIV/AIDS epidemic.
Only 10% of people polled in a recent Research Surveys survey said that they trusted state hospitals, while half said hospitals gave poor customer service and a third said they “do not get things right”. The media is also filled with stories and letters about people being poorly treated when visiting hospitals.
In what amounted to an acknowledgment that all is not well in the country’s hospitals President Thabo Mbeki said his State of the Nation address to Parliament on 3 February this year: “To improve service delivery in our hospitals, by September this year we will ensure that hospital managers are delegated authority and held accountable for the functioning of hospitals, with policy issues regarding training, job grading and accountability managed by provincial Health Departments which themselves will need restructuring properly to play their role.”
Last year, the Democratic Alliance listed “the five worst hospitals” in the country. However, it did not establish baseline norms and standards against which to make this judgement, nor did it assess all of the 388 public hospitals to select the worst.
During December 2005 and in the run-up to the March 2006 local elections, the Health Minister has been paying “surprise visits” to various hospitals and pronouncing many to be working well – sometimes simply on the basis that the floors are clean!
However, it is hard to get an accurate picture of health services nationally. Has there has been a general deterioration of hospital services countrywide or are hospital services getting worse only in certain provinces and/ or certain types of areas (eg urban townships, rural areas)?
The aim of this briefing document is to try to establish what each level of the health system is supposed to do according to available official documents. While some of the information contained in this briefing document is somewhat technical, without this basic technical knowledge, it is impossible to assess any part of the system.
One of the difficulties of coming up with an accurate analysis is the lack of definition of all levels of the health service as well as a lack of official norms and standards for each level. The Department of Health has published norms and standards for the Primary Healthcare level, but it is still in the process of adopting norms and standards for the different levels of hospital services. Thus, the definitions, norms and standards for hospitals are based on draft recommendations that have been made to the Department.
The health system is complex, and the process of transforming it is massive. It is thus important to acknowledge this and to give credit to those hospitals that are trying against all odds to improve the services that they offer to patients. Even the very best run hospitals are struggling to deal with the HIV/AIDS epidemic and the massive shortages of healthcare staff – the two biggest challenges facing the overburdened health system.
But there is also evidence of widespread mismanagement, patient neglect and abuse, appalling standards of care, lack of hygiene, lack of infection control and a lack of accountability to patients of many hospitals and health facilities. It is these issues that we need to uncover.
Context
In 1994, the new democratic government inherited a highly fragmented, inequitable health system with health departments for four different racial groups as well as each of the 10 homelands had its own department of health.
Health services were essentially doctor-dependent medical services biased towards curing existing diseases (ie providing medical care) rather than preventing disease (through provision of services such as clean water and sanitation and education).
There was a strong private health sector which included health professionals in private practice, private hospitals, pharmaceutical manufacturers and distributors and medical aid schemes. Some 80% of the funds spent on health in the country are spent in the private sector, which accounts for almost half the country’s approximately 400 hospitals. Yet only about 17% of the population, the majority white and Indian, have medical aid schemes and use private health facilities. The rest depend on the public health system, which is struggling to meet demand.
In 1994, the ANC adopted a Primary Health Care (PHC) philosophy. This is premised on community development and community participation in the planning, provision, control and monitoring of services.
In 1996, the new Constitution was adopted for the country. According to Clause 27.1 of the Constitution, “everyone has the right to have access to:
a.) health care services, including reproductive health;
b.) sufficient food and water; and
c.) social security, including, if they are unable to support themselves and their dependants, appropriate social support”.
The Constitution compels the state to take “reasonable legislative and other measures within its available resources, to achieve the progressive realisation of each of these rights”. If health care services are getting progressively worse rather than better, this is presumably unconstitutional.
In addition, according Clause 27.3 “no one may be refused emergency medical treatment”. However, there are a number of reports of health workers refusing to treat people who are too dirty or too drunk, while one of the biggest problems at hospitals is the inability of “gatekeepers” at admissions to be able to judge who is in urgent need of emergency treatment.
Constitutionally, health is a “concurrent” function of both national and provincial spheres of government, with national largely responsible for setting policies and provinces largely responsible for implementing these policies. National government is supposed to monitor provincial implementation but lacks the systems and staff to do so adequately. The failure of the national tuberculosis programme to hold provinces accountable to targets and to contain in any real way the TB epidemic is one such example.
Many provinces are still administratively weak and lack the capacity to do what they are supposed to do. In 2004, six out of the nine provinces under-spent their health budgets because of a lack of capacity.
The ANC’s PHC blueprint was adopted by government in the White Paper on Health Services Transformation (1997), which envisages a decentralised, nurse-driven system, based on the district health system where people can get health services near to where they live.
Transformation in the health sector has been hindered by the lack of a legislative framework to guide the process. The National Health Act, giving effect to the White Paper, was only signed into law in 2004, providing guidance on how a national health system should be managed and run.
According to the PHC philosophy, provinces have to devolve responsibility for health to district level and this is a very complex task that requires high levels of management competence to co-ordinate.
Many health districts were established before municipal boundaries were finalised and had to be re-established once the boundaries were set. This demoralised health staff who had already been involved in a very time-consuming previous process of setting up districts.
The country is finally divided in 53 health districts as part of government’s drive to decentralise health services and ensure that citizens in every part of the country have access to a comprehensive package of PHC and district hospital services.
In order to understand how hospital services fit into the health system, it is important to understand the entire health system from primary level.
Primary healthcare
The doctor- and hospital-based model of care meant that people with minor ailments were often treated by doctors at the outpatients departments (OPD) of hospitals. In addition, for many people services such as family planning, immunisation for babies and the management of stable chronic diseases such as diabetes were only available at hospitals. However, this is not an efficient use of resources as there are not enough doctors to see to patients with minor problems.
To use scarce resources more efficiently, government has introduced a hierarchy of health services. Patients using the public health system are now only able to access higher levels of care once they have been assessed and referred upwards by healthworkers at a lower level. The exception to this is medical emergencies.
The first point of entry for South Africans to health services is now at primary level through local clinics and community health centres. These facilities treat what health professionals call “ambulatory patients”, or people who are able to walk and do not need to be confined to bed. From April 1996, services at this level were free of charge.
A Clinic is defined as a facility at and from which a range of PHC services are provided, but that is normally open only 8 hours a day. Certain staff may, how ever, be required to sleep
at or near the clinic so that they are available on call in case of emergency.
A Community Health Centre is defined as a facility that, in addition to a range of other PHC services, normally provides 24 hour maternity and accident and emergency services, and up to 30 beds w here patients can be observed for a maximum of 48 hours. There will be a procedure room but not an operating theatre, patients w ill not be given general anaesthetics, and they w ill not be admitted as inpatients in the community health centre. However, there is some confusion of roles in certain places where community health centres are very similar to district hospitals.
Primary level services are supposed to cover a comprehensive range of “preventive, promotional, curative and rehabilitation services”. Both clinics and health centres are to offer services such as mother and child care, immunisation, family planning, treatment for sexually transmitted infections (STIs), minor trauma and care for those with chronic illnesses (eg diabetes, hypertension).
PHC services are run by nurses, although doctors visit many clinics regularly. If a more specialised level of care is needed, patients have to be referred to secondary level (hospitals) by clinic staff.
Government has developed an Essential Drug List which lays down what medicines each clinic needed to have. Systems for ordering and controlling stock, which had been a huge problem in the past, were improved.
To bolster the decentralisation of healthcare, over the past 11 years, over 1 300 new clinics have been built and over 250 existing clinics have been upgraded. Per capita expenditure on Primary
Health Care has improved from to R58 in 1992/93 to R183 by 2005/06, according to the Department of Health.
The Health Department’s Quality Assurance Directorate developed a list of “core norms and standards for clinics” in 2000 and these are published on the DoH website (http://www.doh.gov.za/docs/policy-f.html).
These include that:
• The clinic renders comprehensive, integrated PHC services for at least 8 hours a day, five days a week;
• The clinic receives a supportive monitoring visit at least once a month to support personnel, monitor the quality of service and identify needs and priorities.
• Doctors and other specialised professionals are accessible for consultation, support and referral and provide periodic visits.
• There is an annual evaluation of the provision of the PHC services to reduce the gap between needs and service provision using a situation analysis of the community’s health needs and the regular health information data collected at the clinic.
• The clinic has a mechanism for monitoring services and quality assurance and at least one annual service audit.
• Community perception of services is tested at least twice a year through patient interviews or anonymous patient questionnaires.
The “norms and standards” also stipulate that clinics need to have medicines and supplies as outlined by the essential drug list (EDL) and a mechanism for obtaining emergency supplies.
All clinics are supposed to have electricity, cold and hot water and a reliable means of communication (telephone or two-way radio), and every clinic is supposed to be able to arrange transport for an emergency within one hour.
While it is commendable that the directorate has published the norms and standards document, there are still not enough resources being allocated to PHC level to ensure that these are achieved.
A survey of PHC facilities (The Facilities Survey) published in 2004 found that almost a quarter of clinics still didn’t have piped water and about about 10% did not have sanitation, electricity and telecommunications. In addition, only about 40% of facilities have trained primary health care nurses and only 30% of clinics are estimated to be visited by a doctor at least once a week. Only about half of all PHC facilities are reported to have functional clinics or community health committees, which means that communities are not being involved in their own healthcare.
One of the biggest problems of building the PHC clinics is the difficulty of attracting and retaining professional nurses (with four years’ training). The burden of health service delivery has been shifted to primary level and clinics have massive patient loads, but very little has been done to make clinics attractive to qualified nurses, who are in short supply.
The Democratic Nurses Union of SA (Denosa) is particularly frustrated that government’s “scarce skill allowance”, which offers certain categories of nurses extra money as an incentive to retain them, did not include PHC nurses as these are the most over-burdened staff.
A survey of clinics conducted in 2003 (2003 Facilities Survey) found that almost a quarter did not provide immunisation every weekday and only half offered antenatal care. The HIV/AIDS epidemic is also taking its toll on the health system at every level. In addition, the roll-out of antiretroviral treatment for HIV positive people has increased the pressure on clinics, which have to test people for HIV and take specimens for CD4 counts and viral loads from those who test HIV positive.
In order for the new hierarchy of services to work, every level has to be functional. Given that resources are limited at PHC level and nurses are often overwhelmed, a number of patients that should have been treated effectively at primary level are transferred to hospitals.
As Sister Somana at Cecilia Makiwane Hospital in East London said in an interview: “The patient load has increased greatly since 1994. This is partly because of primary health care not taking off. The whole of the Eastern Cape is referring patients here. We often see people who should have been attended to by the clinic nurse but, because of the problems there, they end up coming here.”
This precisely what government has been trying to avoid.
Some critics of the PHC system say that in practice all it has done is introduce new levels of bureaucracy, removing control of clinics from hospitals and put them in the hands of inexperienced district managers with no experience of health issues.
Hospital Services
Background
Hospitals are primarily for those who need in-patient care, although all have outpatients departments (OPD) and casualty/ emergency care. Eleven years ago, there were huge inequities in the quality of care between hospitals in formerly black areas and rural areas, and hospitals in urban areas to serve white patients. These still exist today.
In addition, much of the country’s hospital stock was old and run down — particularly in rural areas, townships and the “homelands”. An audit of the hospital infrastructure in 1996 found that two thirds were not up to scratch: one third of the hospitals needed replacement and a further one third needing upgrading.
Since then, 18 new hospitals have been built and a further 190 others upgraded. There are currently 388 hospitals in the public sector in South Africa.
The hospital revitalisation programme is also focusing on improving the infrastructure, equipment, management and quality in 27 hospitals and on modernising tertiary services.
However, assessing the standard of care that hospitals provide is difficult as the DoH has never formally adopted any indicators to do so. But the National Hospital Strategy report submitted to the DoH in 1996 identified 19 priority indicators that could be used to assess and manage hospitals. These indicators include: number of inpatient admissions, length of stay of patients, bed occupancy rates, theatre use, post-operative infection rate; outpatient attendance, emergency attendance, waiting lists for outpatient attendance and staff turnover and absenteeism.
According to the White Paper on Health Services Transformation (1997, hospital management should be decentralised hospital to promote efficiency and cost-effectiveness and hospital boards will be established to increase local accountability and power.
In order to improve hospital services, most provinces have enrolled some of their hospitals in the Council for Health Services Accreditation of Southern Africa (COHSASA) process of accreditation. Cohsasa is a non-profit, independent organisation that aims to “develop and implement standards that define what is needed to provide quality service in all types of South African healthcare facilities and to accredit those that substantially comply with standards”.
Public and private hospitals can apply to Cohsasa for accreditation, which means that they are assessed according to standards developed by the International Society for Quality in Health Care. These standards have been tested and modified over the past nine years in South Africa and comprise of two sections:
Health Care Organisation Management, addressing issues such as: leadership of the organisation, roles and responsibilities of staff, management of information, creation and
maintenance of a safe environment for patients, infection prevention and control, quality management and human resource management.
Patient Care (including diagnostic and pharmaceutical services), focusing on patient rights, access to care, continuum of care, patient assessment, care, planning and the delivery of care and, when appropriate, education of the patient and his or her family.
In addition, most provinces have instituted quality of care programmes, which include either internal or external reviews, and health worker awards programmes.
However, transforming the hospital services is a massive task. At the same time, the health sector is being hit hard by the impact of HIV/AIDS which some researchers estimate has meant that an extra 100 000 patients a year are now seeking treatment for AIDS-related illnesses (“A faltering pulse”. FM October 21 2005.)
“Hospitals appear to have dealt with the increased pressure by raising thresholds for admission and reducing length of stay,” according to Treasury’s review of provincial budgets and expenditure 2001-8.
Along with the AIDS epidemic, the healthcare system is being hard hit by a shortage of skilled healthcare workers, particularly professional nurses. An estimated 42% of all health posts are vacant, with provinces such as the Eastern Cape, Mpumalanga and Limpopo bearing the brunt of the staff shortages. Without the necessary staff, it is impossible to give effect to any norms and standards.
Categories of hospitals
There are three categories of hospitals in South Africa. The most common names used to refer to these categories are District, Regional and Tertiary (provincial tertiary and national central) hospitals although government is now replacing these with the names level 1, 2 and 3 hospitals. As their names imply, they offer different levels of service.
Of the 388 public hospitals, 64% are district hospitals. Secondary and specialised hospitals making up 16% each of the total number. Together provincial and national hospitals comprise less than 4% of all hospitals in the public sector.
The Department of Health has yet to adopt a firm definition of each category or to define what services should be available at each facility or any norms and standards. Draft recommendations on these definitions and levels of care have been developed for the DoH’s Quality Assurance Directorate and should be adopted in the course of 2006. The definitions outlined below are based on draft recommendations made to the DoH, and have yet to be officially endorsed by the department.
|
Table 1. Categories of public sector hospitals Categories of hospital (Public Health Facilities) by province |
||||||
|
Province |
District Hospital (level 1) |
Regional Hospital (level 2) |
Provincial Hospital (level 3) |
National Central Hospital |
Specialised Hospital |
Total Hospitals |
|
EC |
47 |
9 |
16 |
72 |
||
|
FS |
24 |
5 |
2 |
3 |
34 |
|
|
GP |
8 |
11 |
4 |
6 |
29 |
|
|
KZN |
37 |
14 |
1 |
1 |
9 |
62 |
|
LP |
37 |
5 |
2 |
3 |
47 |
|
|
MP |
20 |
5 |
1 |
1 |
27 |
|
|
NC |
22 |
1 |
3 |
26 |
||
|
NW |
24 |
4 |
2 |
30 |
||
|
WC |
28 |
9 |
3 |
21 |
61 |
|
|
SA |
247 |
63 |
6 |
8 |
64 |
388 |