Quality healthcare: An attainable goal for all South Africans?
N P Moyakhe
Nolonwabo Patronella Moyakhe is a sixth-year medical student in the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. This article is published as Nolonwabo won the University of Witwatersrand’s Ethics Alive MPS Undergraduate Bioethics essay competition for medical students sponsored by the Medical Protection Society.
Corresponding author: N P Moyakhe (firstname.lastname@example.org)
Our national Minister of Health, Dr Aaron Motsoaledi, described publicly the challenges facing our healthcare system and discussed the national and provincial measures that are being implemented to allow all South Africans to obtain quality healthcare. One would then certainly argue that the issue of quality healthcare has been debated to its ultimate exhaustion, but at what point do we begin to be silent about pertinent issues, especially those affecting the livelihood of a whole nation? This paper addresses many of the issues highlighted above; it attempts to define what quality healthcare is, in the South African context, and its relationship to the branch of bioethics. It cites current views on ethics and rights in healthcare and the role of individuals and healthcare professionals in improving the provision of healthcare in our country.
S Afr J BL 2014;7(2)80-83. DOI:107196/SAJBL.355
The issue of quality healthcare has been debated to its ultimate exhaustion and it has been deliberated beyond a conceivable alternative to its status quo. But at what point do we begin to be silent about pertinent issues, especially those affecting the livelihood of a whole nation? Is it safe to say that we should be completely resigned to the current state of our healthcare system and merely make do with the few resources available to us?
The question of quality of care raises critical ethical questions, for example, why has this nation seen such an unprecedented and rapid depreciation of the value of human life? And how can we as healthcare professionals assure that this deterioration is halted? Can our healthcare system begin to provide healthcare that is not only of quality but reflects the hard-earned gains of democracy that this still developing country has achieved?
This article addresses many of the issues highlighted above; it attempts to define what quality healthcare is, in the South African (SA) context, and its relationship to the branch of bioethics. It cites current views on ethics and rights in healthcare and the role that individuals and healthcare professionals should have and can have in improving the provision of healthcare in our country. Ultimately this article intends to remind the reader that, as utopian as it may sound, quality of healthcare should never be a privilege but a right.
‘I think it will help us to start sifting fact from fiction. Fact number one: We are a country, which is spending more money on health but having poorer outcomes – that is a fact.’
(Dr Aaron Motsoaledi, SA Minister of Health) 1
The quote above highlights the concern about the SA health system status quo and brings attention to a much contested topic in SA, that of quality of care. The World Health Organization (WHO) advises that countries should spend at least 5% of their gross domestic product (GDP) on healthcare.2 SA spends more than the recommended percentage. As a country we dedicate 8.5% of our GDP to healthcare, yet our health outcomes are surpassed by other developing countries with significantly less of their GDPs dedicated to healthcare services.2 Health indicators recommended by the WHO include life expectancy, child and maternal health and healthcare coverage. In many of these healthcare indicators, SA is ranked among the poorest-performing countries.3
Dr Motsoaledi attributes these poor outcomes to a hospital-centred approach, with a strong curative focus and fragmentation in management approaches. This may be related to programmes or service delivery and uncontrolled commercialism, which undermines principles of health as a public good. He goes on to further convey that, based on all these outlined factors, our country has a major problem of deteriorating quality of healthcare.1
Government’s solution to halting this deterioration and revitalising our healthcare system is National Health Insurance (NHI). NHI is a financing system that will make sure that all citizens of SA (and legal long-term residents) are provided with essential healthcare, regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.4
The government believes that the NHI will substantially improve the quality of healthcare in the following ways:
• It will result in a radical improvement in the quality of services in public health facilities. This means massive investment in improvement of health infrastructure, both buildings and equipment.4
• In every single health institution, certain basic core standards must be complied with; for this reason, the Office of Health Standards Compliance was established.
The formation of this office and the implementation of NHI is a very controversial subject in SA. It is commendable that our government acknowledges the deprived state of our current healthcare system and is introducing this new system to ensure the provision of quality healthcare. As compelling as this idea of change is, many fear that the same errors in management of resources will still be present and the poor will still be victims of inadequate healthcare. Will the formation of the Office of Health Standards Compliance be sufficient to supervise the management of resources and prevent a recurrence of past errors?
Change has to come, and if it comes in the form of NHI, may it not be an empty promise that has no effect on the lives of SA citizens, especially those who require change the most. With adequate planning, accurate organisation and constant monitoring, NHI can begin to equalise the level of healthcare provision in SA, so that even the poorest can benefit from our economic gains.
The SA reality
In SA there are still entrenched disparities separating the rich from the poor. The level of healthcare that one receives is determined by one’s economic class. This goes against the grain of what is clearly outlined in our Constitution (section 10), which says ‘everyone has inherent dignity and the right to have their dignity respected and protected’.5 I argue that dignity is not protected in healthcare if it is determined by one’s economic class. Drastic re-evaluation of our healthcare system should therefore be done, to ensure that the gap in the provision of healthcare between the rich and poor is narrowed, this will facilitate congruence between what is promised and what is actually delivered.
Quality healthcare can be described according to two principal dimensions: access and effectiveness.6 When this principle is applied in the SA context, it provokes two critical questions. Are individuals able to access healthcare? And when they do access healthcare, is the clinical care and interpersonal care effective?6 These two questions highlight the fact that quality healthcare has three main stakeholders: the government, health professionals and civil organisations.
The duty of the government is to provide healthcare resources. The responsibilities of healthcare professionals are to provide quality clinical care and management. The role of civil society is to act as a watchdog on government and healthcare professionals. The level of quality healthcare can therefore be measured according to the effectiveness of these three stakeholders. Quality healthcare can therefore be assessed according to healthcare systems, processes of care and outcomes resulting from care.6
Other criteria often used to assess quality care primarily revolve around patient outcomes, environmental factors and specific clinical-patient interactions.7 Patient outcomes refer to mortality and morbidity after care. The provision of quality health services is proportional to low mortality and morbidity rates, indicating a high level of clinical management and adequate resources or supplies available.
Environmental factors refer to the structural factors that are often fixed aspects of health delivery, including building infrastructure and modifiable factors such clean and safe wards. Nosocomial infections often occur in a setting of poor sanitation and inadequate infection control, usually because of non-modifiable conditions, such as improving staff hygiene practices.7
The efficacy of our healthcare system is deeply rooted in the joint efforts of government and healthcare professionals and civil societies. Each of these stakeholders has duties that they must follow to allow future generations to have equal provision of services. As a country, we must work towards a point where a child born in a remote village in the Eastern Cape has equal and quality opportunities to live and thrive as one that is born in any opulent suburb in SA.
In order to improve and ensure that quality standards are upheld in the health system, the Office of Health Standards Compliance was established by the President on 24 July 2013. The office serves to protect and promote the health and safety of users of health services by monitoring and enforcing compliance by health establishments prescribed by the Minister in relation to the national health system.8
Intersection between quality care and bioethics principles
The four ethical principles that should guide a healthcare professional in interacting with patients are autonomy linked to respect for persons, beneficence, non-maleficence and justice. One of the elements of autonomy is respect for persons.8 Low or non-existence of quality of care erodes the principle of autonomy if a patient’s dignity is not observed. If a patient is recognised as a rational human being who thinks and has feelings worthy of respect, that person should not be given substandard care.
Aspects relating to respect for persons can be found in both international and national human rights instruments and codes.8 Section 12(2) of the SA Constitution, emphasises that everyone (patients included in this instance) has the right to bodily and psychological integrity,5 this highlights the significance of the patient’s ability to be actively involved in decisions, pertaining both their physical and mental healthcare.
Beneficence recognises the duty of healthcare professionals to do good for the patient.8 This principle in summary emphasises the fact that health professionals should maximise good to the patient, in other words do as much as you can to improve the lot of your patients as a professional duty. It can be argued, therefore, that poor standards of care are maximising harm. The Constitution advocates for access to healthcare for all within available resources. This means that the state should and must provide resources and quality basic care to improve the lot of the people.8
Non-maleficence recognises the duty of the health professional not to harm the patient.8 The African Charter advocates for the prohibition of all forms of exploitation and degradation, including cruel, inhumane or degrading treatment.8 The last pillar of ethical principles, justice, is arguably the most important as it deals with fairness and recognises the duty of the health professional to treat patients justly and fairly. It is recognised in the International Bill of Rights, Article 1 of which states that everyone is born free and equal and must not be faced with discrimination on any basis.9 Partiality and injustice therefore have no role in healthcare provision in SA and are possible barriers to provision of quality healthcare to all citizens.
The Bill of Rights in the Constitution, Act 108 of 1996, section 24,5 states that everyone has ‘the right to an environment that is not harmful to their health or well being’. This is a clarion call not to harm patients and to ensure quality of care.
Human rights are the rights we have by virtue of being a human being. They are defined by international human rights instruments and codes.8 From the moment a child is born in SA and registered as a citizen of this country, they are entitled to the best social, economic and educational services that the country can provide. This statement is true whether a person is born in the lowest economic conditions or into affluence. This notion is further reverberated in our Constitution, which affirms equality regardless of racial or socioeconomic differences.5 Healthcare is included in this concept of equality.
Human rights are categorised into civil, political, economic, cultural and environmental rights.8 Observing the rights of individuals therefore includes respecting all categories of their rights. They are, in most cases, universal and are interdependent of each other.8 The link between these different classes of rights is illustrated by the fact that all the categories advocate for the provision for quality healthcare for all.
Political and civil rights promote the autonomy of the individual, indicating that the patient has a right not to be subjected to medical or scientific experimentation.8 Economic and political rights advocate for all patients to have access to healthcare, regardless of the individual’s socioeconomic status.8
The human rights paradigm in relation to ethical principles therefore provides a framework within which healthcare professionals may begin to fight for health promotion and protection8 of their patients. It is therefore critical that healthcare professionals understand the significance of human rights in the provision of quality healthcare.
Our hands and our knowledge are the main tools for the provision of healthcare. The government undeniably facilitates our daily duties by provision of resources, but at the end of the day, healthcare provision is determined by our level of commitment to our profession and our duties to the countless individuals who put their lives in our hands.
The patient’s role and responsibilities
The role of the patient in ensuring that they receive quality healthcare is often greatly underestimated. We as health professionals often conclude that patients seeking medical assistance have no say in how they are managed. This notion should be reconsidered, because SA is currently in an era of legal freedom, where the average South African is fully aware of his or her rights and quick to act against medical negligence. The issue now is making patients understand that when entrusted with the right to free healthcare provision, they also have responsibilities.
As outlined in our Patients’ Rights Charter, patients’ responsibilities include: respecting the rights of other patients and health providers; complying with the prescribed treatment or rehabilitation procedures; and utilising the healthcare system properly and not abusing it.10 It is important that patients keep their records safely to ensure seamless care, and more importantly that they do not abuse the health system, including health workers. These responsibilities will go a long way in ensuring quality of care.
The effect of patients practising these
responsibilities is often not visible, but has a huge impact on
the efficacy and quality of healthcare provided. For instance,
we are often not aware of the huge expenses incurred when
re-treating a defaulting patient, especially for chronic
illnesses such as tuberculosis. The cost of re-treating one
patient does not only result in monetary loss, but it literally
means that less money is spent on treating other people in need.
This will ultimately be a perpetual cycle that needs to be
broken for the sake of the health of this country.
• The WHO ranks South Africa among the poorest-performing countries in terms of healthcare indicators. These poor outcomes are directly linked to the quality of our healthcare. Many factors have been attributed to this deteriorating quality of healthcare, including national economic instability, poor service delivery and shortage of healthcare professionals.11
• NHI is a financing system that has been put in place to improve the current state of our healthcare system, and the Office of Health Standards Compliance has also been established by our government to ensure the success of the NHI. The implementation of the NHI is a step in the right direction to ensure that all South Africans receive quality healthcare.
• In the interim, many South Africans are still lacking adequate healthcare, and the greater proportion of these individuals are those living in poverty. Access to quality healthcare in SA is currently determined by economic class, and this goes against international and national human rights laws, which affirm equality regardless of racial or socioeconomic differences.
• To ensure accessibility of quality care to all South Africans, the role of the government, healthcare professionals and civil society must be clearly outlined, and each of these three entities must be aware of the international and national instruments and codes that guide them. This is particularly important in relation to healthcare professionals who use the human rights paradigm and ethical principles as a framework within which they may begin to fight for patient health promotion and protection.
• It is my recommendation, therefore, that greater efforts should be made to banish continuing inequalities and imbalances. A significant and sustained difference in the current state of our healthcare system can only happen in the setting of united efforts of the government, health professionals and civil societies.11
As a country we have a vast and unfortunately long-standing history of social division and lines of separation. These lines have taken various forms as our country has evolved. They have stood as lines by race and lines by culture, and now we are seeing a barrier that is determined by economic class. I believe that it is a crime against human rights to allow people’s financial means to determine the level of healthcare provision they receive. If we, as a country, want to get to a point where quality healthcare is the norm, we need to level out these inequities and break down barriers to access healthcare.
The official national vision stated by our Department of Health is a brave declaration summarised in one statement: ‘A long and healthy life for all South Africans’.4 The operative word in that statement is all; that one single word should direct our governmental policies and govern our resource allocation.
The current move towards a nationalised healthcare system is a step in the right direction, but much still needs to be done. The mere fact that there are still South Africans dying because of poor healthcare is an indication that we still have a great task ahead of us. As healthcare professionals we must always be conscious of the fact that in SA, the right to quality healthcare often directly equates to staying alive. There will never be grounds on which we can deny anyone the right to life.
Acknowledgements: Dr Norma Tsotsi, director of the undergraduate programme and lecturer at the Steve Biko Centre for Bioethics, University of the Witwatersrand, Johannesburg, South Africa, for her invaluable assistance in the publication of this paper.
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