Rein Sparks is a health activist and an Aspen New Voices Fellow.
Healthcare facilities across South Africa are regularly assessed and rated on their quality and ability to meet patient needs. But the way these ratings are done means that despite an excellent rating, things may not be as they seem.
As South Africa faces a severe third wave of Covid-19, communities deserve a standard of care that can withstand daily scrutiny. During a devastating pandemic, ensuring transparency and accountability in our quality assessment processes is even more urgent.
Imagine this scenario:
Leilah – a suspected case of Covid-19 – enters her local healthcare facility with breathing difficulties. She needs an oxygen mask, which had been confirmed at the facility only hours before her arrival. Leilah’s condition deteriorates rapidly and she dies for lack of a mask. Upon investigation, several compliance issues emerged that were not apparent on the day of the assessment. The establishment was checked and the masks were there, but only because they had been borrowed from a nearby clinic in an attempt to pass inspection. The masks were quickly returned afterwards.
Shortcuts and False Conformity
The South African Department of Health has two quality assurance programs which both assess the compliance of health facilities with minimum health standards.
The department evaluates the quality of care through evaluations conducted by “peers”, which include a group of nurses from the region.
These groups move from site to site, evaluating themselves using a standard checklist and providing a score that assesses the quality of the site. These assessments are part of the Ideal Clinic Realization and Maintenance program, also known as the Ideal Clinic program.
These assessments differ from assessments conducted by the Office of Health Standards Compliance, which uses qualified inspectors under a legislated quality assurance program based on core national standards. The Ideal Clinic program was implemented after the rollout of these standards to create a more sustainable practice program that would enable healthcare staff to engage in quality assurance activities more frequently.
The Office of Health Standards Compliance remains in place to provide oversight, but the two assessments are not monitored or reported in a combined document and sites receive praise on 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 evaluations and can see firsthand the shortcuts taken to get good grades and the strategies used to avoid true compliance. The current health facility rating system is viewed as a box-ticking exercise or short-term hurdle to be overcome to please management or funders.
False adherence continues to lead to gaps in care and even when healthcare facilities receive high marks, patient experience does not back it up. The cost of not fixing it is high.
Evaluations lack objectivity
A critical study from the University of KwaZulu-Natal published in the journal Curationis found that among the many challenges facing the health system in South Africa, lack of objectivity in health facility assessments is one of the reasons why millions of people still experience preventable harm every day due to poor health services.
Even with these dubious attempts to raise scores, only a third of provinces are achieving the scores needed to qualify for aid. In 2018, 47% of sites consulted by the Office of Health Standards Compliance were found to be compliant. During the 2018/19 financial year, the office published 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 failed to meet national baseline standards received awards in their ideal clinic ratings.
A comparison of different assessment results is not reviewed by the Health Compliance Office or the Department of Health and the question remains as to how a site could be both compliant and non-compliant over the course of the same period. Over the three years (2019 to 2021), the government has allocated R19.2 billion to improve facilities and an additional R4.3 billion through the National Health Insurance Fund, but these funds remain largely untouched and may even create an additional perverse incentive to manipulate assessment results.
We must ensure that quality services and vital 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 reporting of results to communities. These external assessments carried out by independent entities ensure that the conclusions are correct and provide training for peer assessors to ensure consistency.
An “obvious solution”
A way forward could be right before our eyes.
Existing mechanisms such as health committees can play a key role in assessments and provide the oversight, assurance and objectivity needed to save lives. These organizations are legally appointed by the provincial health CEMs to strengthen the link between the community and the health facility. Community committee members should be empowered to act as the voice of the community, which is sorely lacking in the evaluation process.
Of course, peer reviews can be a powerful tool – they promote learning opportunities and break down the power dynamics present with external reviewers, and they can foster trust between nursing leadership in facilities. It must not be lost. But the truth remains that peer review alone fosters bias and has led to a culture of competition where earning a positive rating is more important than the needs of the community.
The ratings are linked to the status of the establishment’s management and staff; it is recognized by internal communication channels and rewarded with a brilliant distinction. All of this causes the staff at the facility to twist the truth and paint a picture that all is well when it really isn’t.
Very often, these assessments are not worth the time, effort or resources spent on them and do a disservice to staff and patients. As Covid-19 continues to challenge us to do more and do better, we have an opportunity to engage communities in this critical process through the health committees already in place. With the proper authority, we can empower them to hold healthcare institutions accountable, honestly identify shortcomings so they can be addressed, and ensure assessments do what they are meant to do: protect communities. and give them a real sense of security. SM/MC
This article was first published in Projector.