Hospitals
CHAIRMAN’S REPORT
Time really flies when one is having fun ……. challenges! We have just gone through an eventful year, which has seen the Department of Health getting three Ministers in less than a year. A year also marked by a very unprecedented event in South Africa, viz, the striking of medical doctors.
The September 2007 Healthcare Indaba at which the then Minister of Health, Dr Manto Tshabalala-Msimang decided that the private sector had asked to be regulated”, was followed by the introduction of a bill to amend the National Health Act. This amendment would in effect have been a sophisticated way of price regulation since the proposed bill would then make the NHRPL a potentially binding price for the private sector. These two actions in the Department of Health galvanised the Private Hospital Sector into a hitherto unseen unity. The efforts that went into responding to these threats against the private sector went a long way towards improving public perception in general, and in my mind, also in the minds of some the decision makers. It might also have contributed to the shelving of the proposed amendment!
The NHI It was just a matter of time for the African National Congress to adopt the resolution to “reaffirm the implementation of the National Health Insurance System”. For many years since the era of the Gluckman Commission in 1944, it was apparent that the only way to bring equity in healthcare was to avail universal access to the population. It is the only way to broaden such an essential service that is sometimes limited by lack of funds by the patient. This however does not talk to the “depth” of the services to be provided, which is in essence at the core of what our NHI system should be.
The ANC’s Resolution 53 above goes further to say …. “by further strengthening the public healthcare system and ensuring adequate provision of funding”. It is the implementation of this latter part of the resolution that in my mind should be a preoccupation of all South Africans. It is no more a secret that our public health system is “rotten” to the core, one of the worst in the world, for whatever reason. It therefore has to change and change rapidly. That does not, however mean a hasty implementation of a not so well thought-out health plan, no matter how noble the intentions. It is such a major undertaking that it actually is as important as how our democracy was found, with all those “minutes”, and finally a constitution that is the envy of the world. It is in our capacity as South Africans to debate and come to a consensus on healthcare that might actually be the envy of the world. We need to accept that there are no experts on the National Health Insurance in this country. We are all theorists at different levels of understanding of this concept. It is also unfortunately a concept that opens itself to political manipulation. It is not surprising that at this stage, powerful ideological formations are positioning themselves to influence the outcome and maybe to even implement and manage. The fact that the debate is not yet “quite” in the public forum also makes matters worse. Rumours as to the type and form the NHI document that is being developed by the ANC Task Team are flying and anxieties are building up.
It has become important that we as HASA begin to debate issues around the NHI even before we have sight of the ANC Task Team document. It will prepare us to interrogate and understand it. We might and actually should prepare ourselves to contribute to that document. It is my fervent believe that as it leaves the ANC, it will not be cast in stone and can therefore still be positively influenced.
The NHRPL process From the way the NHRPL process has been run it is evident that there are some members within the Department of Health’s negotiating team that are negotiating in bad faith. These individuals seem to pursue an ideological battle, which is essentially the role of elected officials, rather than just implementing and administering already developed policies.
At a meeting held in December 2008, the Department agreed not to publish the 2009 NHRPL for private hospitals, and that the 2009 reference price list would be based on the 2008 NHRPL and some inflation-based figure. The Department went ahead and published the 2009 NHRPL, in breach of its own undertakings, and is also continuing with the unlawful 2010 NHRPL process. Despite these many engagements, our proposed methodology has neither been accepted nor rejected.
We have thus reached a point where we had to run to the law in objection against an unfair process in determining price regulation, and the manner in which price regulation is being enforced by the Department on us. We as HASA are actually averse to legal battles with the Department, but the laws of the country are there to protect the citizens!
Roadmap for the Reform of the South Africa Health System From July to October 2008, a multi-sectoral initiative consisting of a series of discussions was hosted by the Development Bank of South Africa. This was a very strong political exercise characterised by its inclusivity. It is such inclusivity that should also inform the NHI process.
This initiative took its lead and motivation from the deterioration in South Africa’s Key Millennium Developments Goals performance. The purpose of this colloquium was to map out issues and possible reform priorities for consideration and discussion. This process culminated in the production of a document with the same title, which is a milestone.
The process provided the basis for a social compact of key stakeholders that could, through common purpose and collective action, achieve a more effective health system and better health outcomes.
This Roadmap process has produced a diagnosis of the strategic challenges facing the South African Health system as well as a range of policy responses. Consensus was reached that an important contributor to South Africa’s deteriorating health status arises from institutional weakness within the public health system. There was also an acknowledgement that contrary to “notorious” believes, the private sector has had no contribution to this dismal state of affairs in the public sector!
The Best Care …. Always Campaign Members of HASA have for almost two years been involved in a collaborative effort that seeks to establish a common understanding and standards around clinical governance. A multi stakeholder summit was hosted by the Johannesburg Hospital in order to discuss issues around antibiotic prescribing with its attendant problems and the management of infections in general on the 30th March. An Interim Task team, of which members of HASA form the core, has since been established. A decision was made to embark on mobilizing a systemic, properly co-ordinated, focused campaign that leads to consistent and sustainable best practice at the patient bedside that will deliver tangible and real benefits.
This Antibiotic Stewardship project is now branded “The Best Care…..always” campaign. It is a patient health and safety initiative aimed at supporting South African healthcare organizations to implement specific internationally recognized evidence based interventions in patient care.
The campaign, it was agreed, should be beyond hospital competition and must be focused on a collaborative approach. The major goal of this campaign will be to create a shared vision, strategy and structure in order to improve on patient safety related to antibiotic prescription. The campaign will seek to enlist participant commitment from all key stakeholders and influencers.
The campaign will be marketed and communicated through design and branding of logos and customizable campaign materials, i.e. templates, where hospital logos can be added. Hospitals will be requested to review current practices and set their own goals for improvement. The campaign will also collate lessons learnt from participants. Hospitals will also be advised to incorporate best practice into day-to-day work process. Data will also be collected and collated into industry level information. A possibility of benchmarks will be explored. There is a need to determine the structures required to lead and drive the campaign, including the establishing of costs and the funding of the campaign.
In the short to medium term, it was agreed to embark on the following identifiable projects:
i. Implementation of the IHI Bundles
Initially the campaign will be focused on the prevention of healthcare associated infections and the promotion of responsible and rational use of antibiotics and include the following:
i. Prevention of Ventilator Associated Pneumonia
ii. Prevention of surgical site infections.
iii. Prevention of catheter related bloodstream infections.
iv. Promotion of antibiotic stewardship in Intensive Care Units.
v. Prevention of catheter related urinary tract infections.
A Baseline study on Healthcare Associated Infections was suggested with random sampling from each hospital group or Independent hospitals. An interim goal is to have completed this step by end of June 2009. The aim is to officially launch this sub-project at the FIDSSA conference in August 2009.
ii. Antibiotic ICU Rounds
Some of the hospitals hold antibiotic rounds which are led by either a microbiologist, a senior physician or pharmacist. Again, doctor participation is sub-optimal, as there are no mechanisms in place to encourage regular attendance.
Incentives (e.g. financial, by funders) and disincentives (withdrawal of ICU admission rights) were explored. Punitive measures were viewed as undesirable at this stage. Financial incentives were also regarded as unsuitable as such rounds should be part of patient care in the first place. An option to be explored further is using “reduced motivations” as an incentive to be part of the antibiotic ICU rounds. Impact on Hospital vs professional reimbursement was discussed; hospitals should not be penalized for doctors’ behaviour. Issues to still be explored are; defining minimum requirements for the definition for Antibiotic ICU rounds e.g. who should lead this; Optimum doctor attendance rates (global and individual); Use of antibiotic guidelines; Alternative methods of feedback to doctors.
The campaign strategy is to continuously seek buy in from doctors and their professional societies. We seek to integrate pharmacists, microbiologists, infection control nurses and other infectious disease specialists into antibiotic management processes at local hospital level. It is also important to create systems for measuring antibiotic utilization and infective outcomes, and for sharing best practices.
The campaign should be a collaboration underpinned by trust, and no punitive measures must be taken against any participant. We must also protect our scarce human and financial resources. Members are encouraged to support this campaign since it will lead to improvement of patient safety and patient care.
ConclusionThe coming five years are likely to demand much more unity from the private hospital sector in order to make sure that we continue to offer the type of quality care that our patients are accustomed to. We will be challenged by forces that are mistakenly blaming us for the state of the public healthcare. We must emerge even stronger in our offering of our services to an even expanded population that at present. In order to achieve this, we will need to engage the lawmakers even more and make them to understand concretely what contributions we can make, within sound business reason, to the overall improvement of healthcare in this country.
