Healthcare facilities across South Africa are regularly assessed and rated on their quality and ability to meet patient needs. Currently, the way these reviews are done means that despite having a great rating, things may not be what they appear to be.
As South Africa grapples with a severe third wave of Covid-19, communities deserve a standard of care that can withstand scrutiny every day and during a devastating pandemic there is even more urgency to ensure the transparency and accountability in our quality assessment processes.
Imagine this scenario:
Leilah – a suspected Covid-19 case – walks into her local health facility with breathing difficulties. She needs an oxygen mask, which was confirmed to be available at the facility just hours before her arrival. Leilah’s condition deteriorates rapidly and she dies for lack of a mask. Upon investigation, several compliance issues emerged which were not apparent on the day of the assessment.
The facility was checked and the masks were there, but only because they were borrowed from a nearby clinic in an attempt to pass inspection. The masks were returned quickly thereafter.
Shortcuts and false conformity
The South African Department of Health has two quality assurance programs, both of which assess the compliance of health facilities with minimum health standards.
Currently, the national health ministry assesses the quality of care through peer reviews, which include a group of nurses from the region. These groups move from site to site, rating each other with a standard checklist, and providing a score that assesses quality on the site.
These assessments are part of the Ideal Clinic Achieving and Sustaining Program, also known as the Ideal Clinic Program. These assessments differ from assessments conducted by the Office of Health Standards Compliance (OHSC), which uses inspectors trained in a legislated quality assurance program based on the National Core Standards (NCS).
The Ideal Clinic program was implemented after the deployment of NCS to create a more sustainable, hands-on program that would allow healthcare workers to participate in quality assurance activities more frequently.
OHSC remains in place to provide oversight, but the two reviews are not currently monitored or reported in a single combined document and sites receive praise for the peer-reviewed program as opposed to the legislative program.
In my experience working in public health quality assurance in government, municipal and NGO spaces, I design and conduct assessments and can see firsthand the shortcuts taken to getting good grades and the strategies used to avoid true compliance. The current health facility assessment system is seen as a checkbox exercise or a short-term hurdle to overcome in order to appeal to management or funders.
False adherence continues to lead to gaps in care and even when healthcare facilities receive high marks, patient experience does not confirm this. The cost of not fixing it is high.
Evaluations lack objectivity
A critical study of the University of KwaZulu-Natal published in the journal Curationis found that among the many challenges facing the health system in South Africa, the lack of objectivity in evaluations of health facilities is one of the reasons where millions of people still suffer preventable damage every day due to poor health services.
Even with these dubious attempts to increase scores, only a third of provinces achieve the scores necessary to qualify for support. In 2018, 47% of sites consulted by the Office of Health Standards Compliance were found to be compliant. I
In fiscal year 2018/19, the Office of Health Standards Compliance issued an annual inspection report in which it stated that only 137 out of 730 (18.7%) health facilities assessed in South Africa were compliant.
Interestingly, the same health facilities listed that did not meet national core standards received awards in their Ideal Clinic ratings.
A comparison of the various assessment results is not considered by the OHSC or the Ministry of Health and the question remains as to how a site could be both compliant and non-compliant during the same period.
Over the 3-year period (2019 – 2021), the government allocated 19.2 billion rand to improve facilities and an additional R 4.3 billion via the National Health Insurance Fund, but these funds remain largely untouched and may even create an additional perverse incentive to manipulate assessment results.
We need to ensure that quality services and life-saving facilities are available to communities and that compliance assessments are carried out with integrity and without bias. This means ensuring greater accountability in peer reviews and self-assessments, including external verification and transparent communication of results to communities.
These external reviews from independent entities ensure that conclusions are correct and provide training for peer reviewers to ensure consistency.
An “obvious solution”
A way forward might be right in front of our eyes.
Existing mechanisms such as health committees can play a key role in assessments and provide the oversight, assurance and objectivity necessary to save lives. These bodies are legally appointed by the MECs of Health in the provinces to strengthen the link between the community and the health establishment.
Community committee members should be empowered to act as the voice of the community, which is sorely lacking in the assessment process.
Of course, peer reviews can be a powerful tool – they promote learning opportunities and remove power dynamics present with external reviewers, and they can foster trust between nursing management in institutions.
It must not be lost. But the truth remains that peer review in itself fosters bias and has led to a competitive culture where getting a positive ranking is more important than the needs of the community.
The grades are linked to the status of the establishment’s management and staff; it is recognized by the internal communication channels and rewarded with a brilliant distinction. All of this pushes the staff at the facility to twist the truth and paint a picture that everything is fine when it really isn’t.
Very often, these assessments are not worth the time, effort or resources given to them and do a disservice to staff and patients. As Covid-19 continues to challenge us to do more and do better, we have the opportunity to involve communities in this critical process through the health committees already in place.
With the right authority, we can equip them to hold healthcare facilities accountable, honestly identify gaps so that we can address them, and ensure that assessments do what they are meant to do: protect communities and make them feel real. of security.
* Sparks is a health activist and Aspen New Voices member.
* This article first appeared in Projector