Dr Crisp was speaking about Covid-19, what government has learned, and what it means for the implementation of the NHI and the future of healthcare in SA, at the GIBS Healthcare Industry 2020 Conference. “We’ve learned an enormous amount about infection prevention and control (IPC),” said Dr Crisp. “It’s been in the media quite a lot because of the personal protective equipment (PPE), the shortages and the corruption but what’s been less reported is just how much we’ve learned about the importance of IPC. In the ward space, in theatres, you have to assume that every single patient that you meet is infected because there’s so many asymptomatic patients in that environment. And we’ve learned the importance of IPC committees within the healthcare environment and valuing our cleaners and other people who otherwise perhaps passed by in the corridors.”

The COVID-19 pandemic is unlikely to change the contents of the NHI Bill in any drastic fashion [Image: Shutterstock].

“The second thing around health service delivery is that we’ve missed out on a lot of non-Covid-19 care during this period. I think the big lesson is still coming, but people have been afraid to come to the health services or they have come but we’ve not been able to look after them in the way we would have liked to,” cautioned Dr Crisp. “And whether we like it or not, we have let a number of our programmes slip and the consequences of that are going to meet us in the days to come.


Rather than downplaying the dire state of the public sector infrastructure, even before the pandemic, Dr Crisp admitted that a lot of it was old, dilapidated, and inappropriate for use. “But a huge amount of work has been done around the upgrading and improvement of the interior of quite a lot of buildings in the public sector. And because we needed more bed space, there are areas of hospitals that have been improved upon. Whatever improvements have been made are going to remain after Covid-19, so that’s something we should appreciate.

“The second thing is we’ve appreciated the dearth of equipment and the deficiencies were identified quite early on,” he said. “In some cases, we’ve succeeded in getting the equipment replaced or implemented. In others we’ve got waiting lists of up to four months because of global supply challenges. But even if the equipment comes late, it means that we’re going to be upgrading quite a lot of equipment and implementing things that we didn’t have before in particular in hospitals.


“In terms of staffing we’ve learned a whole lot of things,” said Dr Crisp. “Some of them have been negative and need to be fixed, for example how long it takes to get people appointed, and how difficult it is to get part time people appointed for short periods of time.

“But the biggest and ongoing lesson is around occupational health and safety. All provinces are now under instruction to implement occupational health and safety committees in all hospitals. They should have been there all the time and should have been operating according to the law, but they haven’t and that will be something that will remain positive after Covid-19.”


Adamant that the distribution of medicines was already improving significantly prior to Covid-19, Dr Crisp acknowledged that with the demand for dexamethasone and a few other primary medicines, “things have swung a little from time to time”.

“PPE has been one of the biggest learnings, and there are all kinds of failures and successes in the PPE environment. But a lot of us have learned more about the quality and about the fit of PPE, how to structure contracts to make sure you get sufficient sizes, why PPE should be managed on the pharmaceutical system and not on the normal storage system, and so forth. So there have been lessons and improvements.”


Dr Crisp described digital data management as one of the biggest areas of improvement. “This has been a large part of the NHI project so we had quite a lot of hardware and systems in place, but suddenly there was this huge demand for data, improved quality and completeness of that data, ease of transfer of data, and improved analytics for decision taking. And on all scores, there’s been quite a significant improvement and that will remain as a legacy, if you like, from Covid-19 going into the NHI.”


“When Covid-19 first started every province rushed off to make almost knee jerk reactions and were quite uncoordinated in the beginning. Each province was doing its own thing,” Dr Crisp lamented. “That is slowly but surely coming under control and I think everyone’s now starting to understand why it’s important that there should be quite serious coordination between the provincial administrations, and of course with the private sector as providers as well.”

Although he insisted there’d been an improvement in national policy directives and in the clinical guidelines, Dr Crisp admitted it was not as good as it should be.

And then of course there’s the corruption fiasco. “It is bothering us all and leaving us quite red faced and angry about our failure to control. But fortunately, there are steps being taken to intervene now,” he said.


“Covid-19 has illustrated in my opinion how vulnerable and fragmented our health system is. It’s shown us that our current financing models are a disaster and make us all extremely vulnerable – both private and public alike – and they’ve highlighted massive procurement challenges not only in the health sector but throughout the public sector that need to be addressed,” said Dr Crisp. “For me it’s clear that if we don’t overhaul the health system, none of that will improve for us the users of the health system and citizens going forward.

“Secondly, we need to formalise the forums that we’ve had temporarily in place to deal with Covid-19 so that we can put our heads together for everyone living in the country. We need to accelerate the implementation and stop talking about things, because frankly we don’t have all the answers. And, if we don’t embark on some kind of, I hesitate to use the word but, experiment and make sure that we test what we are doing, Covid-19 has shown us that we can do it. And even if we have to change it a little bit from here to there, we will find ways to improve the way we do systems. It’s time for tough choices,” Dr Crisp said.

“As far as the GPs are concerned, we need to finalise the quality standards that have been sitting around in the corridors of power for the last three years, and we need to find ways to get Office of Healthcare Standards certification for GP practices so we all know what we’re dealing with.” He stressed the need to finalise the definition of coding of primary healthcare benefits. “This has been long designed, a lot of work’s gone into it, but it’s not been properly defined and coded so it’s hard to count and hard to allocate who’s doing what, and what the outcomes are. We need to make it very clear what we are expecting as the GP’s role in multidisciplinary district teams going forward, and how the NHI intends to contact these private practitioners in the contracting units for primary healthcare.

“As far as the rest is concerned, and the hospitals, it’s very obvious, we need complete digital integration,” said Dr Crisp. “We have already embarked on that process, just prior to Covid-19 we had an excellent and extremely well attended seminar forum to look at interoperability and the national standards and we need to finalise process. And then we need to pursue with vigour the diagnosis related groups (DRGs) and find a different way of how we’re going to pay for hospital care going forward.”


In closing Dr Crisp insisted that other than the timeframes, Covid-19 hadn’t changed anything about what is in the NHI Bill and that what was written in the Bill and the amendments the Bill will bring to other pieces of legislation were essential to the success of building a proper service the NHI will be able to finance. “Fundamentally, to the structure of what needs to be done for the country’s health system, nothing’s changed. But hopefully we’ll come out of this with much more understanding of the need for solidarity, and that my health is your health, your health is my health, and in Covid-19 we are now very clear that if I protect my health it’s not necessarily enough – we have to protect everybody’s health if we’re all going to be safe.”


AUTHOR: Nicky Belseck, medical writer