Picture: ISTOCK
Picture: ISTOCK

Previously unpublished government records paint a grim picture of a failing public health system, a worrying lack of disclosure about its shortcomings, and an oversight mechanism that has done little to raise standards.

Data obtained from the Office of Health Standards Compliance (OHSC), based on inspections it conducted in the four years to March 31 2016, show that only 89 of the 1,427 public hospitals and clinics had met the office’s 70% pass mark.

And of the 320 facilities that were subjected to repeat inspections, the vast majority failed to improve in any significant way between visits.

The office used 13 metrics, ranging from the availability of medicines to operational management, to rank the facilities, and each of those comprised several components that were weighted according to the gravity of the threat they posed to patient safety.

Umhlanga Clinic in KwaZulu-Natal, which scored just 18% when it was inspected in 2014 and failed to meet the 70% compliance threshold for a single metric, fared worst in the rankings. Hundreds of other clinics fared little better.

While the data clearly highlights a crisis, it also contains a number of anomalies.

Only two of the 149 clinics evaluated by the OHSC in the Western Cape, generally considered to have a well-run health administration, scored 70% or more in the most recent inspection. In Tshwane, 16 of 47 clinics made the grade.

Steve Biko Hospital in Gauteng was the top-ranked facility, scoring 96%. However, the DA’s Jack Bloom recently highlighted complaints about the state of its casualty department and outstanding repairs.

The OHSC data also appear to be out of kilter with the provincial variations in maternal mortality rates — a proxy indicator for how well a health system is functioning and closely monitored by the government.


Source: ALEX VAN DEN HEEVER, UNIVERSITY OF WITWATERSRAND and SOUTH AFRICAN HEALTH REVIEW
Source: ALEX VAN DEN HEEVER, UNIVERSITY OF WITWATERSRAND and SOUTH AFRICAN HEALTH REVIEW

Business Day calculated a weighted average for the hospital scores in each province, using bed numbers. Gauteng, North West and KwaZulu-Natal get virtually the same weighted average quality scores for their hospitals (72.23, 73.57 and 71.25 respectively) as the Western Cape’s (74.52), yet their maternal mortality ratios are much higher at 141, 179 and 185 per 100,000 live births respectively than the Western Cape’s 77 per 100,000 live births.

Until now, details of the OHSC’s investigations have been kept under wraps, impeding efforts to hold facilities and provincial health departments to account. The lack of disclosure has also made it impossible to gauge whether the office is doing its job effectively, or ascertain whether patients are likely to get quality care.

The OHSC’s failure to publish its findings is perplexing given that it lacks the legal muscle to enforce standards: in March it complained to Parliament that it could not take action against hospitals and clinics because regulations giving it the power to do so were still in the pipeline.

Business Day accessed the OHSC’s high-level inspection data using the Promotion of Access to Information Act (PAIA) after the body repeatedly rebuffed requests for information. And then it relinquished the bare minimum — only the final scores — and declined to answer follow-up questions or respond to a request for more details.

A second PAIA application was filed to obtain the 13 composite scores. Despite agreeing to this second application, the OHSC provided an incomplete data set, omitting component scores for the 2015-16 fiscal year despite having given a written undertaking to do so.

In its reticence to publish its findings the OHSC differs markedly from similar regulators, such as the UK’s Care Quality Commission, which posts its reports on its website.

OHSC acting CEO Bafana Msibi repeatedly side-stepped the question when pressed to explain the lack of disclosure, saying only that findings were presented to the provincial health MECs once a quarter.

The OHSC’s work is key to Health Minister Aaron Motsoaledi’s plans for improving public health facilities in preparation for National Health Insurance (NHI).

While precise details of his ambitions for universal healthcare have yet to be fleshed out, the government intends tasking the OHSC with accrediting facilities that are to provide services under NHI.

A credible inspection process will be key to convincing citizens that they will receive quality care under the NHI system, and that the government is justified in demanding higher taxes to pay for it.

Msibi says the inspection teams sent out by the OHSC arrive unannounced and spend up to five days scrutinising the larger hospitals.

"Sometimes management is a bit arrogant, but I call the head of department in the province if we have resistance. We’ve never had a facility where they can’t inspect," he says.

The OHSC clearly has capacity constraints: at the last count it had 35 inspectors, who had the task of assessing more than 4,000 public health facilities.

Its inspection records make this abundantly clear, as it has failed to adhere to its aim of reinspecting failing facilities within six months. It managed to do so for barely 6% of the hospitals and clinics that did not pass muster between 1 March 2012 and 30 September 2015.

It has consequently lowered the bar and now says it will only reinspect facilities that score less than 50%: worse, it is only aiming to reinspect 25% of such failing facilities in the current fiscal year.

At some point in the near future, Motsoaledi is expected to promulgate regulations giving the OHSC powers to sanction noncompliant facilities. While these powers are long overdue, the regulations come with a sting in the tail, as they are set to expand the OHSC’s mandate to include private health facilities.

Without a significant boost in resources, it is questionable whether the watchdog will be up to the task.

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