Much like the R196m Health Market Inquiry (HMI), will the SA Lancet National Commission simply produce yet another report on healthcare for government to ignore?
Ethics, responsibility and accountability within the SA’s healthcare system were the focus of the annual Ethics Alive Imbizo held at the University of Witwatersrand.
Speakers Professor Laetitia Rispel (Department of Science and Technology/ National Research Foundation chair and Professor of Public Health, Centre for Health and Policy, School of Public Health, University of the Witwatersrand) and Mark Heywood (who stepped down as executive director of Section 27 in December) ensured a full house.
SA LANCET NATIONAL COMMISSION
Launched in May 2017, the SA Lancet National Commission was charged with the responsibility to conduct a country specific analysis on quality of care consistent with the overall aims and objectives of the Lancet Global Health Commission on high quality health systems in the sustainable development goals (SDG) Era (HQSS). Co-chair of The SA Lancet National Commission, Prof Rispel discussed the purpose, intricacies and findings of the Commission.
However, she also shared her frustration and scepticism that anything would come of the final report. Referencing The Constitution, the Reconstruction and Development Programme, the White Paper on the Transformation of the Health System, the National Development Plan, and the 2018 National Health Insurance Bill as examples, Prof Rispel said: “SA is good at developing policies, we could probably teach Policies 101, we could probably fill an entire room with our laws and legislation – and they’re excellent – we just don’t implement them.”
A contested exercise with lots of complexities Prof Rispel said the Commission had, “left many of us feeling quite traumatised and exhausted by the process.”
THE PROBLEM WITH SA HEALTHCARE SYSTEM
Commenting on the fact Prof Rispel isn’t expecting much to come of the report; Heywood expressed concern that this was part of the disease affecting SA’s healthcare system. “We have a mountain of diagnostic reports of what is wrong with different parts of the healthcare system in SA. Some of them are very public, some of them are less so. But what’s wrong with the healthcare system is certainly not that we don’t understand what’s wrong with the system. What’s wrong is we lack the leadership to act on the evidence, which is one of the greatest challenges.”
Charting ‘how we get from a nightmare to a new dawn in healthcare’ Heywood identified three themes:
1. Narratives: “There isn’t just one story; we have to look at public healthcare facilities, private practice, accessibility, etc.”
2. Quality: “The quest for quality healthcare must occupy us all, and in some way even take precedence over access, and certainly over policy.”
3. Meaning: “There’s still a contest over meaning in health and how we understand the cause of the crisis context/meaning.”
LANCET REPORT: AN INCONVENIENT TRUTH
“This report has been nearly ready for months,” said Heywood, “but there’s a dispute over how it is released, because it may paint a picture or tell a story that is not a convenient story at the moment, and doesn’t fit in with the narrative, and may cause questions to be asked about the shape of National Health Insurance (NHI).
Not about the principle of NHI, but about the shape of the proposal that has been put on the table at the moment and where do we start in our quest for equity, equality, and access to healthcare. There is a dispute, this report is being held back, and I know because I’ve talked to some of the highest people in the healthcare department and they’ve told me it’s being held back.
“When looking at SA’s healthcare system there are multiple narratives,” said Heywood. “While they may be different, the question is how we understand these apparently contradictory stories. For example, we can have greater access to healthcare services than we’ve ever had before, and that’s been the reality since 1994, but we can also have greater inequality in healthcare services than we’ve ever had before.
So, the question is, are those two contradictory truths, or is it simply possible for both to be true at the same time? I believe there’s greater inequality and most of that inequality continues to play out on the terrain of race, class and poverty.
“We have had world-class successes in our healthcare system, such as the response to HIV, where we now have 4.5 million people who have access to antiretroviral treatment, and we have reduced mother to child HIV transmission from about 20% to fewer than 2% of pregnancies in 15 years. That is a huge success. But there’s no question that success is now under threat as the response to HIV is threatened by equality issues.”
But you can have HIV and you can have Life Esidimeni, you can have HIV and the cancer crisis – more people die of preventable cancers than died at Life Esidimeni. Another clash of truths is you can have the best Health Minister in the history of SA, passionate, leads from the front, but have the worst health outcomes in the last five years.
Even the President calls the situation in SA’s healthcare system a crisis. And not just the public healthcare system but the whole healthcare system. However, we tend to focus on the public healthcare system. “The Health Market Inquiry (HMI) report – which is another one of those reports we spent R196m on – risks being ignored unless we make a fuss about it. The HMI report found there’s a crisis in the private healthcare system as well. Although the two mirror each other, they are very different.
But I guess the question we need to ask is, with these contradictory truths, which truth must we latch onto and prioritise in order to try and sort out the mess?
“To answer the question, I think we should look towards The Constitution because it’s our most important accountability mechanism and measure as to whether or not we are fulfilling our duties. What makes health in SA unique is that the starting point has to be that our highest law says: ‘Everyone has a right to healthcare services including reproductive healthcare’.
When it comes to children, it says they have the right to quality basic healthcare services. This is since The Constitution became law in 1997, but our failure when it comes to The Constitution is, we haven’t even defined what basic healthcare is. What is the full package of basic healthcare the government must provide – immediately? The president can’t say ‘no resources’, he can’t say ‘we’ll get to this basic package in the next twenty-five years’.
The Constitution says, ‘all of these duties must be performed diligently and without delay’. “The bottom line is we’re not meeting what The Constitution demands of us. Life Esidimeni is an example of us not meeting the dignity required by The Constitution. Lack of access to abortion clinics in Gauteng is an example of us not meeting the requirement of access to reproductive healthcare.
We have to conclude that as much as we can celebrate, and build on and empower ourselves with the successes, we must also focus on the failings.” The principle behind the sustainable development goals is if you pick up the lowest in society then you raise everyone. We have to look at the worst of the healthcare system and address the worst in order to raise the system as a whole.
“So, what will it take to achieve equality? I believe the answer to that is in the Lancet report that we’re being prevented from seeing. It will take a revival of ethics. There’s a loss of ethics throughout the system. Not just in the frontline providers in the healthcare system that tend to get most of the blame. There’s a loss of ethics in Discovery Health, in Netcare, and in the people who make vast amounts of money exploiting the crisis in the healthcare system.
There’s a loss of ethics at management level of national and provincial health departments. Combined with the loss of ethics there’s an explosion of impunity linked to corruption. When we did the research on corruption in healthcare in 2012 it was R20 billion a year. It’s probably about R40 billion a year that is lost in corruption now. So, we have to revive ethics.
CORRUPT OVERSIGHT MECHANISMS
“The second thing is to revive the oversight mechanisms. We’re very glib in the way we talk about the healthcare system without thinking about what the different parts of the ecosystem needed to interact with each other to get results. Very importantly, Rispel mentioned regulatory oversight, whether this be in terms of the South African Medical Association (SAMA), the Office of Health Standards Compliance (OHSC), the Health Professions Council of South Africa (HPCSA), the South African Nursing Council (SANC), and a whole bunch of others.
Almost all of them are in crisis or have been in crisis. The mechanisms meant to prevent corruption have been corrupted, our HPCSA being a prime example. If we don’t fix those institutions, then the only people who can provide oversight are civil society. The problem is civil society is too small, weak, and underfunded to fulfil that type of roll.
The conundrum is we are failing, but why are we failing? For the most part we have enough money, we have a massive healthcare infrastructure (both public and private), we have academic institutions that can train world-class doctors and nurses, and we have everything a healthcare system needs. So where are we going wrong? If someone can figure out how to gel all these parts together then we’ll get to the bottom of everything.
“The Constitution is useless if we treat it as nothing more than a piece of paper. Part of the solution is active citizenship; it creates the responsibility and accountability. We have accountability as healthcare professionals, we have accountability at institutions like Wits, we also have responsibility as citizens to speak out on these issues. If we don’t speak out, we risk reaching a point of no return, where it’s impossible to put the healthcare system back together.
But we’re not there yet. “If the Lancet report was actually taken seriously, and implemented and planned around, it might in fact present a pathway to fixing many of the problems that we’re currently confronted with in the SA healthcare system.
SA LANCET NATIONAL COMMISSION
1. Review current knowledge and evidence
2. Analyse country level data
3. Develop rigorous evidence on the current state of health system quality and quality improvement efforts
4. Build an analytic capacity for quality measurement and analysis
5. Contribute to the overall findings of the Global HQSS Commission-state of quality of healthcare in low- and middle-income countries in the SDGs era
6. Make country specific policy recommendations on high quality health systems.
1. Gaps in ethical leadership, management, and governance contribute to poor quality of care
2. Poor quality of care costs lives
3. Malpractice cases and medical litigation are threats to the realisation of the right to healthcare in SA
4. Human resources for health crisis will undermine the achievement of high-quality universal health coverage
5. Gaps in health information system to measure or monitor quality and its improvements
6. Fragmentation and limited impact of quality-of-care initiatives.
4 OVERARCHING RECOMMENDATIONS
1. Enhance governance and leadership for quality and equity
2. Revolutionise quality of care
3. Invest in, and transform human resources for health in support of a high-quality health system
4. Measure, monitor, and evaluate to ensure a high-quality health system.
1. High-quality UHC is a moral and ethical imperative
2. Planned NHI system is a major opportunity for transformation
3. Implementation of recommendations will require leadership, investment, and accountability.