National Public Health Institutes of South Africa (NAPHISA) Bill: public hearings day 1

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Health

16 August 2017
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The Committee met to hear public input on the National Public Health Institute of South African (NAPHISA) Bill. The South African Medical Research Council (SAMRC) expressed support for the Bill but stressed the need for better coordination of different organisations’ efforts to improve healthcare. It saw the opportunity for cooperation between NAPHISA and the SAMRC, sharing of tasks and implementing others separately. It called for the SAMRC to have greater representation on the NAPHISA Board.

Members raised various concerns about antagonism between different organisations, the SAMRC’s motivation to gain influence from NAPHISA and the way in which it was engaging with the Department of Health – there was discussion on areas of cooperation between the SAMRC and NAPHISA as well niche areas between the two. There was agreement the SAMRC would submit a report on Friday about the areas of agreement and disagreement between it and the Department.

The Cancer Association of SA (CANSA) highlighted the lack of overarching policy to coordinate different efforts to tackle individual cancers in SA as well as a lack of locally relevant statistics on how the population was affected. Underlying this appeared to be poor coordination and planning on the part of the Department as it wasted the efforts of organisations such as CANSA and international partners such as the World Health Organisation.

Members were confused about the way the information was put forward by CANSA – ultimately, Members decided the allegations raised were serious and thus needed to be investigated albeit that the allegations were not relevant to the issues at hand in terms of the Bill.

Input by the Household Surveys Foundation focused on why Tuberculosis (TB) has had such a devastating effect on SA and using this as an example of poor implementation of health policy. The Foundation called for greater community involvement in raising funding and in providing information saying this should be coordinated at a ward level. It criticised the Department’s behaviour towards medical practitioners, communities and international partners. The Foundation hoped for the NAPHISA Bill to improve the poor coordination of the Department.

Although the information provided by the Foundation was not relevant to the issues at hand, Members praised the initiatives of the Foundation and its ground-up approach to improving government’s efforts.

The National Institute for Occupational Health described how categorisation of workplace hazards did not cover infectious diseases, such as TB, which were acquired because of dangerous working conditions. Furthermore, communities close to mines and other industries were vulnerable to workplace-generated dangers even if residents were not necessarily in the workplace itself. The lack of environmental health being included under occupational health currently, or in the Bill as it stood, meant these conditions will remain unaddressed. Poor working conditions did not only affect workers and wider communities, but SA and its economy as well.

Input by the South African Civil Society for Women’s Adolescents and Children’s Health (SACSoWACH) noted that the National Health Insurance policy had the unrealised potential to strengthen the health system to support the survival and healthy development of children, adolescents and women in the country. The organisation expressed concern with the absence of early child health development from the current national health system and identified it as a critical national issue and burden standing in the way of sustainable development. The current national health system did not focus on early development but instead on child survival. SACSoWACH therefore proposed a shift in focus and a need for strategic leadership to move the national health system to a more balanced approach which did not only focus on survival but also on ensuring the optimal development of children.

The organisation further proposed the inclusion of adequate technical and strategic leadership capacity in National Public Health Institute of SA (NAPHISA) to profile and drive an early childhood development focused planning around SA’s national health system. This was identified as a key method to aligning the National Health Insurance (NHI) and NAPHISA with the early child development policy which was approved by Cabinet in 2001. The current early childhood development discourse in the country revealed the major stumbling blocks in terms of development and sustained health of the population was rooted in poor early child development. Furthermore, SACSoWACH highlighted major gaps in the current health system that the NHI and NAPHISA can address.

The focal point of the organisations’ submission was that early childhood was one of the most effective ways to redress inequity, the roots of which were established early in life, and the need for a life-course approach that provided the support to healthy development from concept through youth and into adulthood. In sum, SACSoWACH proposed the involvement of key experts in maternal, adolescent and early health development at both a strategic leadership and technical level to ensure that early development was not provided too late.

The National Institute for Quality Improvement answered three key questions in relation to quality in the healthcare sector. Firstly, what was quality improvement?  Secondly, how was quality improvement beneficial to healthcare in this county? Thirdly, why should NAPHISA have a national institute of quality improvement? The submission highlighted the current health system cannot sustain quality and this was not due to lack of resources but rather process issues with healthcare professionals. The presentation was centred around three key concepts, namely, quality (extent to which a health care system was able to meet the expectation and needs of patients and provision of services which were effective and safe), quality assurance (meeting the basic needs of safety in an organisation) and quality improvement (identifying gaps in the current service delivery against the service excellence the Department of Health hoped to achieve).

The presentation proposed the development of a National Quality Institute to facilitate quality improvement because it spoke to the ability to coordinate learning as the Department and sustain the learning over time. The institute would be responsible for training healthcare professionals, standardising work flow processes, piloting interventions programs led from the front by building the capacity of quality improvement advisors from within and institutionalising patient centeredness. The National Quality Improvement Institute was advocated for as the root to achieving quality health care.

Members questioned how much of the input by the last two submissions could contribute to the Bill. Further questions were posed on how there could be improvement in the way patients were treated, or improvement of the environment, to avoid hospital infections.

Meeting report

Introductory Comments

The Chairperson welcomed everyone present and noted the importance of the National Institute for Occupational Health (NAPHISA) Bill for SA. She explained the procedural rules of the meeting after which invited parties made oral submissions on the Bill. 

South African Medical Research Council

Adv. Nkosinathi Bhuka, National Manager, Legal Services, SAMRC, explained the detail of the presentation was included in the formal, paper submission made to the Committee on the Bill – this was particularly in terms of training and research processes. Moving to the presentation, SAMRC highlighted health conditions could be improved through technology transfer and research. To do so, resources already available should be made use of. Skills and competence were available and these should not be duplicated. There was space for collaboration with existing entities so the Bill should help formalise cooperation and utilise scarcely available skills.

The SAMRC would like to be represented on government structures. It also saw there were areas of overlap with NAPHISA such as in the areas of surveillance, health systems, non-communicable diseases and communicable diseases – the Council however recognised there were areas of separate specialisation between it and NAPHISA. NAPHISA should identify areas for research and the SAMRC should provide the knowledge base required for these priorities. To make this work, continuous feedback and communication between the two would be required.

Discussion

Dr P Maesela (ANC) saw too much overlap between NAPHISA and the SAMRC and feared the organisations could become antagonistic if there was unnecessary competition between them – it would be better for the two organisations to pool resources.

Mr A Mahlalela (ANC) reminded the Committee the SAMRC fell under the Department of Health. Seeing as the Bill related to the Department, concerns should have been resolved at a departmental level. He asked what discussions took place particularly in terms of how NAPHISA could expand collaboration. He thought the SAMRC did not see its interests as aligned with the Department as the Department was already represented while the Council needed to be asked to be represented.

Ms S Kopane (DA), in relation to concerns over funding for research, asked how exactly research would be improved.

Adv. Bhuka reiterated the SAMRC supported the Bill. In terms of antagonisms, he believed there were niche spaces for different organisations and a large-scale merger would not necessarily be the best solution. He confirmed time consuming consultations took place but the Bill was tabled before these consultations could be completed.

Dr Marlon Cerf, Chief of Staff, SAMRC, said resources were limited and thus needed to be pooled. Greater collaboration was sought to improve health conditions. Collaboration would involve various other entities, such as universities, meaning a merger of all entities involved would not be possible. Board representation for the SAMRC would help to continue efforts of collaboration. Funding would be a critical issue in the future.

Adv Bhuka added the SAMRC wanted board representation in order to actually participate and not just fulfil an observer position – a position which was already afforded to the Department. In terms of areas of overlap, he believed the role of the Bill would be to create a framework while recognising different spaces for separate actors to operate in.

Mr Mahlalela asked if the SAMRC proposals had already been agreed to by the Department.

Adv Bhuka replied that the Department was engaged but not everything was agreed upon - SAMRC made an independent submission to the Committee because of this.

The Chairperson had difficulty understanding why an independent submission would be necessary if the Council consulted with the Department. She thought the SAMRC was trying to contest a new space.

Dr Cerf responded that better coordination was necessary – comments made by the Committee were supportive and noted.

Mr Mahlalela asked if it was possible for the SAMRC to shed more light on the matters the Council and the Department agreed and disagreed on.

Adv Bhuka said it was possible but was not sure if the Committee had enough time to do so.

The Chairperson felt the SAMRC was making matters difficult as the Committee was working within time constraints. The Council could make use of time made available by a presentation which was cancelled to thrash matters out.

Ms L James (DA) pointed out the diagram provided in the SAMRC presentation showed some of the areas of overlap – what were the effects on funding?

Dr Cerf said funding had decreased so the SAMRC was seeking external funding as well as consolidating resources with the department.

Mr Mahlalela agreed the Council should be given time to figure out the areas of agreement and disagreement with the Department. He proposed a written response on the matter from the Council be provided to the Committee by Friday.

The Chairperson, after checking that there was agreement to the proposal, supported it.

Dr Maesela advised that the SAMRC saved time by consulting with the Department before submitting.

Adv Bhuka was worried about the short time in which to consult with the Department but agreed to submission from a written response to the Committee by Fiday.

Cancer Association of South Africa

Prof Michael Herbst, Head of Health, CANSA, expressed the Association’s support for the Bill. On the subject of amalgamation, he warned against different organisations being dumped together and simply given a new name. He described CANSA’s efforts for greater reporting on cancer and that government had still not compiled a cancer registry. The result was that the extent of the disease in SA was not actually well known. He referred to the World Health Organisation’s (WHO) warnings of increases in cancer in the globe where middle and low-income countries would be worst hit. In 2015 the WHO in SA advertised for proposals on a Cancer Control Programme - Prof Herbst and others submitted, were asked for further information and then heard nothing else - he believed someone in the Department of Health, with no experience ultimately wrote the programme. The Department had been given support and funding from the WHO but had not used it – the Department produced policies for some individual cancers, such as breast and cervical, but had no overarching programme to coordinate them. He reiterated the need for a cancer registry based on the national population. The Department, up until this point, had simply used general, global statistics. He asked the Committee how it thought it would be possible for SA to plan for the future in this way. CANSA needed to be able to provide information to the public, but the statistics provided were limited and full of errors.

Discussion

The Chairperson asked Prof Herbst to clarify what he meant by saying that no information was provided – how was this conclusion reached?

Prof Herbst said the written submission made to the Committee should make it clear what was being referred to.

The Chairperson pointed out that she was referring to the verbal presentation.

Prof Herbst responded there was no overhead national cancer control programme – such a programme was important to help different organisations know what to do. He reiterated the WHO attempted to develop one. He highlighted the importance of the National Cancer Registry to provide yearly statistics on the burden caused by the disease – the current registry had many errors and was only complete up until 2012. He mentioned that CANSA had been able to raise R3.2 million externally to help aid this but that government expressed no interest in using it.

Ms Kopane felt the CANSA presentation was a complaint of a broken relationship – she pointed out that representatives of the Department of Health were present and so could comment on the topic. She asked why the WHO contacted Prof Herbst directly instead of approaching the Department.

The Chairperson reminded Ms Kopane that this was a presentation and there would be opportunity to ask for the input of other delegations at a later point.

Dr S Thembekwayo (EFF) asked CANSA if it was in support of the Bill and what amendments it would suggest. The Department needed to look into the procurement strategy used to write programmes and policy. There are skills in SA that need to be used - better communication strategies were important for making this possible.

Mr Mahlalela suggested Prof Herbst return to the Committee at another time because the presentation it made had no relation to the matter before the Committee today – another space should be created for CANSA to raise its issues again but these issues needed to be dealt separately from the NAPHISA Bill.

The Chairperson asked Dr Maesela if he was happy with the above proposal.

Dr Maesela agreed with the proposal.

The Chairperson thanked Dr Herbst noting that another opportunity should be created for CANSA to raise its issues with the Committee.

Prof Herbst thanked the Committee and apologised for approaching the presentation in the wrong way - CANSA supported NAPHISA and he hoped problems described in his presentation would not happen to it.

The Chairperson thanked him for the support for NAPHISA but said that serious allegations were raised in the CANSA presentation to which the Department would have to respond.

Household Surveys Foundation

Prof Welile Shasha, Public Health Specialist, Household Surveys Foundation, pointed out that his submission would focus on removing tuberculosis (TB) from SA.

In 2015, along with diabetes, TB was the main cause of death in SA, in combination with AIDS. The submission set out a four-stage approach for removing the disease within ten years – these stages included identification, curing current cases, preventing future ones and eradication. He posed the question of why there were still so many deaths caused by TB when it was actually quite a simple disease to treat. The main reason for this, according to the Foundation, was the weakness of the health system – while the system carried all four stages identified, it did not do so well enough. Another reason was healthcare being too reliant on government funding along with poverty and unemployment which placed many people in vulnerable positions.

Prof Shasha was pleased that the Director-General of the Department was present at the meeting. He proposed an “integrated people approach” to treatment of TB - this would require household surveys, assisting people that were not independent, further enabling communities that were normally only passive receivers and enabling more inter-departmental cooperation within government. The Foundation bemoaned the fact that the Department was not people-focused and did not know about communities on the ground. While healthcare was also implemented by NGOs this was difficult because many of the organisations kept information to themselves and did not cooperate with locals who know more about their communities. He said specialists, such as himself, needed more information on the ground. Communities could raise money and collect information. He said headmen were prepared to coordinate this but ward councillors less so - he hoped NAPHISA would help with this. Delineation of wards was important but communities still needed to come to the fore themselves - NAPHISA could provide a better framework for this to take place. Finally, he suggested the cost of the TB eradication strategy be around R400 million per year.

Discussion

The Chairperson said that a lot of what Prof Shasha referred to concerned functioning of the Department so those issues would have to be discussed at another time. The Committee needed to stick to discussing what was relevant to its agenda for the day.

Prof Shasha said there was community representation provided for in the National Health Act but this ineffective – this representation needed to be improved at ward level. He had communicated with the Department before but it did not want anything to do with him. He hoped NAPHISA would be different but was worried it would not be.

Ms Kopane thanked Prof Shasha for his passion and for doing things of his own accord – he should not be discouraged if his input did not relate to the Bill because people like him were needed on the ground and the country would make use of him.

Prof Shasha thanked Ms Kopane.

Mr H Chauke (ANC) agreed that Prof Shasha’s expertise was needed – he urged Prof. Shasha to stay with the Committee even though his input was not relevant to the Bill. He thanked Prof. Shasha for what he was doing.

Dr Thembekwayo also thanked Prof Shasha for his willingness to serve SA - she praised his ground-up approach that started at community level as things did not always have to be top-down.

Dr Maesela asked Prof Shasha why he had quit.

Prof Shasha, while not intending to single out names, accused the Director-General seated behind him. Prof Shasha said his offers were never made use as the Department preferred to hire expensive overseas consultants who knew less.

The Chairperson apologised for the fact that Prof Shasha’s submission would not be made use of as it was necessary to focus on the business of the day. She urged him not to worry as the Department was behind him.

National Institute for Occupational Health

Dr Sophia Kisting, Executive Director, National Institute for Occupational Health, focused on surveillance as a contribution to the National Institute for Occupational Health and NAPHISA. 15.4 million people went to work every day in SA and came into contact with various hazards - this caused widespread absenteeism. Improving occupational health played an important part in the development of the economy and the country as a whole. The diseases taken into account when evaluating workplaces did not include infectious diseases such as TB. Substances released into the environment such as diesel and asbestos, were dangerous and can cause diseases if inhaled. This in turn reduced the work life of employees and affected the SA economy through decreased productivity. Diseases such as TB were also often considered “community acquired diseases” that did not involve the workplace even though locations, such as mines, were so dangerous. Environmental health must be included along with occupational health in NAPHISA. The work environment can affect others who were not necessarily workers themselves. For example, communities living close to mines were affected by similar conditions but found themselves in a categorisation loophole. Not all residents were workers and there was overlap between residence and work-environment conditions. She concluded that the consequences of poor conditions would continue to hamper South African health until regulations were brought into law. The Bill did not include environmental health and safety. The likelihood of NAPHISA coming about in the current financial year was unlikely so there was still an opportunity to include such provisions.

 Discussion

Dr Maesela pointed out there was a lot of work for the Institution to do and he hoped it had the staff and resources needed. He found the conditions of workers living around mines particularly worrying - cooperating with the Department of Environmental Affairs would be more efficient in addressing these conditions. He added that poverty was the greatest cause of ill health.

South African Civil Society for Women’s Adolescents and Children’s Health

Ms Kira-Leigh Kunhert, Programme and Advocacy Manager, SACSoWACH, outline the organisation was a civil society coalition for the advancement of women’s adolescent and children’s health in SA. In line with SA’s democratic principles, the organisation will try to offer more than one voice during the presentation. SACSoWACH was relatively new and was established about two years ago, in partnership with the Department of Health, to bring about a more coordinated civil society voice to help with planning, monitoring and advocacy. It was made up of 23 organisations nationally that range from organisations in maternal child health, child survival and human development. The organisation had a shared commitment to supporting the strengthening of the health system and ensuring the survival, healthy and growing development of young children, adolescents and women. SACSoWACH believed that the National Public Health Institute of SA (NAPHISA), together with its counter-part, the National Health Insurance Policy, had the unrealised potential to strengthen the health system to support the survival and healthy development of children, adolescents and women in the country.

Ms Kunhert said NAPHISA is the structure to provide strategic leadership in shaping the national health system as it unfolded under the National Health Insurance (NHI) and its drive to universalise healthcare.  At the moment, what was critically absent in the current national health system and the pilot of the NHI was the issue of early childhood development - early childhood development was a critical national issue and a burden standing in the way of sustainable development. Early child development in this context referred to cognitive development of young children. It was a matter of priority that needed to be addressed in order to secure sustainable development. The current national health system did not focus on early development but instead on child survival. There was a need to shift focus and a need for strategic leadership to move the national health system to a more balanced approach which did not only focus on survival but also on ensuring the optimal development of children, which they had a right to, and on which the development of SA depended.  

Last year, Cabinet approved an integrated national early childhood development policy that placed responsibility for the early development of children in the first 1 000 days from conception until the child reached the age of two on the health system. However, the NHI and NAPHISA Bill is not align with that focused responsibility - in order to ensure the national health system was aligned with the obligations of the policy, strategic leadership was required. There was also a need for the allocation of appropriate resources in terms of human resources, financial resources, monitoring, evaluation and surveillance. NAPHISA had a very critical role to play in providing that leadership. SACSoWACH therefore asked that the NAPHISA structure consciously and deliberately focus on early childhood development by having technical and specialists on the board and that there be a focused review of the current NHI framework against the early child development policy to ensure imperatives were embedded in the policy within SA’s national health system. SACSoWACH asked that NAPHISA have adequate technical and strategic leadership capacity to profile and drive an early childhood development focused planning around SA’s national health system.  

The NHI’s priority was to universalise access not just to therapeutic services but also to preventative and promotive health care especially to the most vulnerable. The current early childhood development discourse in the country revealed the major stumbling blocks in terms of development and sustained health of the population was rooted in poor early child development. With the NHI scheme and the programmes rolling it out, the focus in terms of development became an issue for the first time when the child entered Grade One, i.e.  the orientation the health system brought to early child development was late child development. Structures like NAPHISA were critical because the shift required high levels of meaningful political buy-in, which was translated in terms of appropriate health systems, therefore leadership was critical. The leadership was lacking at the moment hence there were gaps.

Ms Lene Overlad, Chief Executive Officer, SACSoWACH, said maternal and child health, nutrition and development were key factors to achieving the NHI goals. There were major gaps in the current health system that the NHI and NAPHISA can address - these included slow progress in reducing maternal mortality rates, improving the provision of adolescent health, the burden of development difficulties and disabilities and maintaining the focus on child survival health. There had also been persistent high malnutrition rates with little progress during the past 30 years - this increased the risk of poor child development. Furthermore, there were high levels of preventable disability and development delays in young children which were often undiagnosed and untreated and when it was picked up it was often too late. Sight was an example of this - 80 percent of early development was vision based but many cases of poor vision were not detected early enough before the age of six. The moment the child went to school and underwent vision screening through the elaborative eye health screening program that SA introduced, it was already too late. Hence the importance of screening programs before the age of six and before entry into formal schooling.

SACSoWACH stressed that early childhood was one of the most effective ways to redress inequity, the roots of which were established early in life. There was a need for a life course approach that provided the support to healthy development from youth and into adulthood - this required early and comprehensive health promotion and prevention through the NHI particularly aimed at maternal and child health.

Ms Kunhert concluded by reiterating that SACSoWACH’s main request was that the NAPHISA structure include key experts in maternal, adolescent and early health development at both strategic leadership and technical level to make sure early development was not provided too late.

Discussion

The Chairperson highlighted that, in essence, the SACSoWACH submission supported the NAPHISA Bill. While she found the presentation interesting there were some issues she would have liked to challenge the presenters on. She said SA’s population was constantly growing and the challenges faced by the Department, as the custodian of the health sector in terms of service delivery, came from a particular past which health programmes were trying to address - the Department was working on improving these plans. She agreed early child development was an important phase and there was a distinct difference between “crèche” and an early child development program. Other departments should be involved in such a program such as the Departments of Social Development and Basic Education – further discussion with SACSoWACH could be had on the matter. Once the Committee completed its deliberations, issues highlighted in the submission would be factored in and taken into account in the legislation to enable the health sector to focus on health from conception to death.

NAPHISA Public Hearings – A National Institute for Quality Improvement

Dr Shrikant Peters, Public Health Medicine Registrar, began the presentation by providing a brief personal introduction. He highlighted the presentation would focus on answering three key questions – (1) What was quality improvement?  (2) How was quality improvement beneficial to healthcare in this county? (3) Why should NAPHISA have a national institute of quality improvement?

Within the discussion of quality and value in healthcare, it was imperative to take a patient centred approach. To illustrate this point, the presentation took an extensive look at a personal health care journey that demonstrated the issues of quality in the health system. The journey involved a patient that was diagnosed with diabetes and hypertension - overtime the patient’s cardiac failure worsened. With deterioration the patient was referred to the secondary level facility (Mahatma Ghandi Memorial Hospital in Durban). There was a two-week delay in the referral and at the level two facility it was found the level one facility missed that the patient had a hospital acquired infection. Eventually the patient was referred to a level three facility (the King Edward VIII Hospital in Durban) - the patient’s health continued to deteriorate leading to the patient having a stroke. The patient’s doctor attempted to get a CT scan however access was denied due to proper procedures not being followed and thus the patient had to be referred back to a level two facility. These were not issues of resources but issues of process with the healthcare professionals – the public health system not being able to sustain quality was not an abstract term.

Quality referred to the extent to which a health care system was able to meet the expectation and needs of patients - it involved providing services which were effective and safe. Quality assurance involved meeting the basic needs of safety in an organisation. It was a compliance exercise where external parties came in to measure hospitals on various matrices based on national core standards or ideal clinics to ensure there were basics in place. There was another step called quality improvement - it is very clinical in its methodology, aimed to identify gaps in current service delivery against the service excellence the Department of Health hoped to achieve and encouraged healthcare professionals to look at structures and processes they worked with daily to improve their practice over time.

Quality in the healthcare sector was defined in 2001 by the policy on Quality and Healthcare. The policy highlighted problems including healthcare professional making avoidable errors, variation in services, inaccurate diagnosis and inefficient use of resources. Further, referral systems are inadequate, drug shortages, long waiting times and poor record keeping. These inefficiencies are measured in life lost and costs that escalate. The recommendations made by the policy included providing appropriate training for healthcare professionals, investment in quality improvement systems and health evaluation and redesign which is a key public health intelligence function to build capacity for quality improvement. Quality improvement requires three things: leadership, learning as an organisation and the ability to create organisational change at the level of healthcare facilities.

Dr Peters said quality improvement looked at how medical practitioners can improve their work processes to achieve excellent levels of care and what was the best which could be done with available resources. The methodology around this taught healthcare professionals to apply the scientific method to healthcare services. Quality improvement required healthcare professionals to measure themselves over time in cycles by looking at the data generated and looking at work processes in cycles. There were certain principles and tools in quality improvement one of which was lean management - it encouraged healthcare professionals to look at value from a patient perspective, to analyse and improve service flows and to continuously improve on clinical process by reducing waste and to pursue perfection. The methodology had been fragmentally applied in the SA case.

Dr Peters outlined there were three cases in which quality improvement had been applied – e.g. the Antiretroviral (ARV) Program. SA had the largest ARV and Prevention of Mother to Child Transmission (PMTCT) program in the world which registered some major success. This was achieved through the use of quality improvement methodology. The national core standard required that healthcare professionals prescribed medicine and medical supplies available but it did not clearly state how professionals were supposed to go about doing that. In 2002, the Department started the PMTCT program - after three years it evaluated the program and found it was largely ineffective. After three years of distributing ARV to mothers who were HIV positive, rates of infection were still 20 percent. The Department then called quality improvement advisors and the advisors piloted a quality improvement methodology with several districts across the country and formed learning networks to teach quality improvement methodology. Overtime, the quality improvement plan reached national level where the results included a decrease of rates of infection from 23.2 percent down to 2.4 percent in ten years.

The second example was preventing healthcare associated infections - the national core standard required  professionals to have strict infection control practices and policies in place but it did not clearly state how healthcare professionals should do their work. Best Care Always was a quality improvement methodology being rolled out in the Western Cape and Gauteng - it was a grouping of best practices which were all evidence based and resulted in a tremendous decreased in infection rates. The maternity unit in Cape Town managed to reduce its septic rate by 73 percent in three years. The value of quality improvement lied in the ability to generate data, change healthcare processes and monitor the data overtime. Staff at maternity units were able to show actual decreases in rates of infection over time and this was key to changing culture and practice in health facilities.

The third and last example was reducing waiting time at emergency facilities, an issue SA was in dire need of. The national core standard required healthcare professionals to have methods to attend to patients who required care as quickly as possible however it did not tell doctors how to structure their working day. The staff at Tshwane district hospital consulted with quality improvement advisors and it was identified that prolonged waiting time was an issue. Over a period of six months, the average waiting time changed from nine hours to one and a half hours without any additional resources – problems the hospital faced was analysed along with the data over time.

Dr Peters concluded by asking why there should be a national institute for quality improvement and stressed quality assurance because of the current absence of quality improvement. Several countries had public health institutes which had quality improvement units, for example Australia had the Clinical Excellence Commission, the United Kingdom ran the NHS improvement program and Theda Care and Catalysis while the United States had organisations that embarked on a lean management program to improve services without costs.

The reasons to establish a National Quality Improvement Institute spoke to the ability to coordinate learning as the Department and sustain the learning over time. The current quality assurance lacked the capacity to maintain, monitor the quality improvements and share best practices across the country. The Institute would therefore be responsible for training healthcare professionals, standardising work flow processes, piloting interventions programs as the PMTCT did, lead from the front by building the capacity of quality improvement advisors from within and institutionalising patient centeredness.

In terms of gaps in the current health system’s quality compliance, quality had been defined through the national core standards and systems put in place to measure compliance but what had not been done was the placement of systems to continuously improve healthcare quality across the country – this was the role of a National Improvement Quality Institute. The National Development Plan stated “the health system should be effective and efficient and provide quality care to those who need it” – a National Improvement Quality Institute would be the root to achieving quality health care.

Discussion

The Chairperson did not want to assume that by virtue of the presentation Dr Peters supported the Bill. She would have appreciated if the presentation was more centred towards addressing the content and clauses in the Bill. She reiterated the purpose of the meeting – while the content of the submission was important, it was unsuitable for the agenda before the Committee today.

Ms C Ndaba (ANC) appreciated the presentation but agreed with the Chairperson that the Committee needed to strictly consider inputs on the Bill. She asked Dr Peters what input he had on the Bill based on the issues raised in relation to NAPHISA in the presentation. The presentation proposed many good initiatives in terms of quality of the healthcare system but these were issues the Committee would not be able to respond to today.

Dr Maesela asked Dr Peters what he thought could be done to improve the way patients, or the environment, was treated so as to avoid infection in hospital. The perspective he got from the presentation was that the public hospitals were a bit laissez-faire in terms of hygiene – if this was so, what could be done about it?  Strict hygiene did not need a school of hygiene to learn - it simply required water, soap, a towel and disinfectant. Was this because there was lack of registrar supervision over interns?

Dr Peters responded stating that an improvement was possible because there was something beyond the basics that compliance measures cannot measure - that was the science behind the healthcare process. It moved faster than policies and guidelines. While basic hygiene was salient, in terms of improvement practice, healthcare professionals found that if you apply standardised protocols i.e. patients were washed, blood, sugar and temperature were monitored and every patient was given antibiotics before an operation, sepsis could be reduced by 73 percent. However, protocols were not always followed. Protocols were different for different medical schools, facilities and provinces. The only way to improve practice in a facility was to show clinicians that improvements were possible by showing them data through the quality improvement methodology.

Mr Mahlalela noted that the submission proposed two more divisions to the Bill which would cover healthcare process improvement and health informatics – he asked Dr Peters to speak to these two additions and clarify how they would fit into the work to be done by NAPHISA. He asked why it was proposed analysis and improvement of healthcare service delivery be included as a core function of NAPHISA – did Dr Peters feel strongly about this?

Dr Peters responded by acknowledging he was being bold by suggesting more divisions because divisions required budgets. He said the functions should exist because quality improvement division should be part of NAPHISA as healthcare professionals needed to be shown how to improve quality and to empower themselves to change the systems they worked in. Quality was not something that was imposed but was something delivered every day. With the health informatics division, at the provincial level, the health informatics division was responsible for generating electronic health record for the province – it has been successful so far and he would like to see a similar system at the national system. It was a public health function as it spoke to data usage around healthcare. These were the key functions he felt were not covered in the current format. The current divisions spoke to the quadruple burden of disease but there was a lack of overarching public health intelligence function and how to use the data from healthcare process to improve the response to the problem the Department of Health faced. Clinicians should be able to own quality improvement for themselves.

The meeting was adjourned.

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