Embedding quality at the core of universal health coverage in South Africa
Authors: Malebona Precious Matsoso, Jeanette Rebecca Hunter, Vishal Brijlal
Journal: The Lancet Global Health (2018)

South Africa's White Paper on National Health Insurance1Department of HealthNational health insurance for South Africa: towards universal health coverage.http://serve.mg.co.za/content/documents/2017/06/29/whitepaper-nhi-2017compressed.pdfDate accessed: August 15, 2018Google Scholar represents the government's statement of intent on achieving universal health coverage (UHC)—ie, to provide all people with access to a common set of comprehensive health services of sufficient quality, while also ensuring that the use of these services does not expose the user to financial hardship. The White Paper recognises that the health and development of South Africans is largely dependent on the social determinants of health, and that the best way to obtain improved health outcomes is through a multisectoral, multistakeholder primary health-care (PHC) approach that puts the individual at the centre of health and development programmes. The White Paper recognises that service coverage and affordability are crucially important, but not sufficient, to ensure achievement of UHC. As such, a strong emphasis is placed on improving the quality of care at the entry point into the health care system (ie, the PHC system). In South Africa, although PHC facilities are the communities' first point of contact with the health system, inadequate service provision, overburdened clinics with long queues, and poor quality of services has resulted in many people bypassing PHC facilities and going straight to hospital outpatient departments where services are perceived to be better. The National Department of Health thus started preparation for UHC through National Health Insurance by improving the quality of PHC services. The Department's rationale was that improved PHC services would increase communities' confidence in these services, and decrease the occurrence of PHC services being bypassed. The Ideal Clinic Realisation and Maintenance (ICRM) programme was designed in response to the deficiencies in the quality of PHC services, and to lay a strong foundation for the implementation of National Health Insurance. An ideal clinic is defined as a clinic with good infrastructure (ie, physical condition and spaces, essential equipment, and information and communication tools), adequate staff numbers, adequate medicines and supplies, good administrative processes, and adequate bulk supplies; such a clinic uses applicable clinical policies, protocols, and guidelines, and partner and stakeholder support to ensure the provision of quality health services to the community. The definition and framework of the ideal clinic is in line with the focus of The Lancet Global Health Commission on High-Quality Health Systems,2Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; (published online Sept 5.)http://dx.doi.org/10.1016/S2214-109X(18)30386-3Summary Full Text Full Text PDF Scopus (1041) Google Scholar which states that health system quality in low-income and middle-income countries should be centred on people: improving their quality of care and the value they derive from the health system. Facilities are inspected by the Office of Health Standards Compliance, which is mandated with protecting and promoting the health and safety of health-service users through monitoring and enforcing compliance with prescribed norms and standards.3Republic of South AfricaNational Health Amendment Act (12 of 2013). Government Gazette, Cape Town2013Google Scholar Yet the importance of communities' voices in the governance of PHC facilities is evident from the fact that a key element of an ideal clinic is a functional clinic committee. The ICRM scale-up process, in its third year of implementation, uses an implementation research model and tracks the progress of facilities in improving their scores against required standards. In its first year of implementation (2015), the programme increased the number of clinics that achieved ideal clinic status from 0% to 9%, and then from 9% to 30% in the second year, and from 30% to 43% at the end of the third year. Despite the intensity and priority attached to the programme, a more rapid scaling up has been hampered by key human resource shortages and slow infrastructure improvements at the remaining clinics. Poor financial and supply chain management practices have been identified as contributing factors to these two challenges. The Health Systems Trust annually publishes a District Health Barometer. This annual publication provides an overview of the performance of public health services in South Africa. The 2016–17 edition shows a positive trend for population health indicators that are influenced by primary health care services.4Massyn N Padarath A Peer N Day C District health barometer 2016/17. Health Systems Trust, Durban2018http://www.hst.org.za/publications/Pages/District-Health-Barometer-201617.aspxDate accessed: August 15, 2018Google Scholar Additionally, in 2017, an independent patient experience of care survey also indicated a positive correlation between ideal clinics and patient satisfaction. 168 clinics and community health centres were randomly selected among all primary health-care facilities in South Africa, with stratification by district and ideal clinic score category. In total, 7124 patients participated in the study. Most patients reported a positive experience of care (76·5%) and a similar proportion (74·8%) were satisfied with the services received in the facility. The proportion of positive experiences of care was much higher for high-scoring facilities than for low-scoring facilities. Participants accessing high-performing ideal clinic facilities reported the highest proportion of positive experiences of care (82·2%) (figure). The growth in ideal clinic numbers is an indication that attention and corrective interventions focused on specific weaknesses in PHC facilities do have the required effect. This growth was achieved through focusing on processes to improve Integrated Clinical Service Management, infrastructure, human resources for health, service-user waiting times, financial management, and supply-chain management. National and provincial health departments, with the assistance of national and provincial treasuries, should now speed up infrastructure and staffing improvements and correct the procurement processes that lead to many clinics functioning without the required medication, consumables, equipment, and furniture. We declare no competing interests. High-quality health systems in the Sustainable Development Goals era: time for a revolutionAlthough health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. Full-Text PDF Open Access