South Africa's healthcare system lacks real data

Natalie Zimmelman

While efforts have been made to measure indicators for sustainable development goals for the nation, these are relatively limited and are largely focused on mother-and-child statistics and total healthcare objectives. Allied to this, there are virtually no clinical outcomes recorded in the private healthcare system.

“There is no sustainable data that allows for reflection on the tertiary healthcare system in any depth or in terms of quality of service provided. Measurements are few and far between and include proxies for quality or outcomes measures,” says Natalie Zimmelman, CEO of the South African Society of Anaesthesiologists (Sasa).

The National Department of Health has long held a legislative mandate to establish a national clinical database, but there hasn't been much progress.

The crisis in hospitals

The department continues to focus its energies on the crisis in hospitals, particularly centrally located hospitals, which means tertiary and quaternary healthcare are not receiving the attention they deserve – including a benchmark database on which to build to improve healthcare services for all South Africans.

“The establishment of a national clinical outcomes database is also in line with one of the key recommendations of the SA Lancet National Commission, which proposed a greater emphasis on measurement, beginning with a dashboard that captures quality metrics across the entire health system, both public and private,” says Professor Laetitia Rispel, professor of the School of Public Health at the University of the Witwatersrand.

“Improved measurement will inform governance decisions and guide improvement,” she adds.

In the public domain the under-resourced Office of the Health Standards Compliance undertakes a limited number of health facility visits, but data generated is primarily administrative or process-based rather than outcomes-based.

The proponents of the country’s healthcare system are entrusted with maintaining quality healthcare, yet the health department’s annual reports tend to provide more of a general overview of the system’s functionality rather than specific measurables.

All of which begs the question: why aren’t there measures of important elements such as clinical outcomes? If such information was well managed and made readily available, it would enable members of the public to have a means of determining, for example, which doctor or hospital would be a better choice.

Not a simple process

So why doesn’t South Africa have an accessible, sustainable database of clinical procedures and outcomes as is mandatory in many other countries, such as Sweden, for example?

The short answer is that it’s not a simple process. The reasons are manifold:

• It is difficult to define and gather data given that so many variables come into play. How would one measure quality, for example?
• South Africa’s population is not homogenous, which means risk adjustments have to be made, for example, in a region that has a high prevalence of tuberculosis. International measures cannot be applied in the South African context because it is so unique. Our system does not make provision for home-based care, for example.
• If the data shows that a surgeon had more returns to theatre than a peer, would it be because that surgeon is bad at his job or because they are so good that everyone wants to use them for the most complex cases?
• Every measure needs to reveal the truth of a specific scenario, which means all stakeholders need to agree on every element used in the system.
• Measures of quality need to be verified, bearing in mind that anything that is incentivised might skew the data. Any possibility of manipulating the system to achieve desired outcomes also needs to be eliminated.

To establish an equitable system for measuring clinical outcomes, all stakeholders – patients, doctors, nurses, specialist doctors, anaesthetists, private and public healthcare facilities, funders, the health department, medical aid schemes, all health-related councils, administrators and regulators – need to be proactively involved in the creation of a centralised database.

Legacy of mistrust

“As things stand in 2019, the healthcare system is fragmented, with a few powerful role players and many weak ones. There is a strong adversarial relationship and legacy of mistrust – earned by all sides – among role players. There is no national, independent or standardised system,” says Zimmelman.

The recent Health Market Inquiry by the Competition Commission dedicated an entire chapter in its preliminary report to this issue. It recommends the establishment of an independent outcomes, measures and reporting organisation to drive the collaborative gathering of health outcomes data.

In effect, the National Health Act (No 61 of 2003), makes provision for the department of health to create such a database, but there is no centralised digital record of patients available in South Africa.

Despite this handicap, private individuals have set about capturing data, a function that rightfully rests with clinicians. A recent poll by Sasa indicates that 98% of its members are in favour of a centralised database that will enable them to improve service delivery.

The goal should be to build a system with all the right governance elements in place to meet legislative requirements. It would need to address data security and the Protection of Personal Information Act regulations, and above all, be a system driven by clinicians that patients can rely on.

Zimmelman says industry attempts to standardise communication and classification have not gone beyond coding for billing purposes. “A new data-gathering system would have to be risk-adjusted to cater for all sectors of the population and each measurement would have to be identified and codified.”

This is not going to be a quick, easy or cheap fix, but if it is managed as it should be, an up-to-date database of clinical outcomes will be of inestimable value as a benchmark from which to grow and improve the healthcare industry for the benefit of practitioners, national bodies and, ultimately, the patients themselves.