While the third wave hits South Africa, health facility quality ratings give a false sense of security

René Sparks is a health activist and an Aspen New Voices Fellow.

Health facilities across South Africa are regularly assessed and rated on their quality and ability to meet patient needs. But the way these assessments are performed means that despite an excellent rating, things may not be what they seem. 

As South Africa faces a severe third wave of Covid-19, communities deserve a standard of care that can stand up to scrutiny every day. During a devastating pandemic, it is even more urgent to ensure transparency and accountability in our quality assessment processes. 

Imagine this scenario: 

Leilah — a suspected Covid-19 case — enters her local health facility with breathing difficulties. She needs an oxygen mask, which had been confirmed as available in the facility just hours before she arrived. Leilah’s condition quickly deteriorates and she dies because there was no mask. Upon investigation, several compliance issues emerged that had not been apparent on the day of the assessment. The facility was checked and the masks were there, but only because they were borrowed from a neighbouring clinic in an attempt to pass the inspection. The masks were swiftly returned afterwards. 

Shortcuts and false compliance

South Africa’s Department of Health has two quality assurance programmes which both assess the compliance of health facilities to the minimum health standards. 

The department benchmarks quality of care through assessments conducted by “peers”, which include a group of nurses within the local area.

These groups move from site to site, assessing each other with a standard checklist and providing a score that rates the quality at the site. These assessments form part of the Ideal Clinic Realisation and Maintenance programme, also referred to as the Ideal Clinic programme.

These assessments differ from the assessments conducted by the Office of Health Standards Compliance, which uses trained inspectors in a legislated quality assurance programme based on the National Core Standards. The Ideal Clinic programme was implemented after the roll-out of these standards to create a more sustainable, hands-on programme that would allow health staff to engage with quality assurance activities on a more frequent basis.

The Office of Health Standards Compliance remains in place to provide oversight, but the two assessments are not being monitored or reported on in one combined document and sites are receiving accolades on the peer-assessed programme as opposed to the legislative programme. 

In my experience working in public health quality assurance across government, municipal and NGO spaces, I design and conduct assessments and can see first-hand the shortcuts taken to gain good ratings, and the strategies used to avoid true compliance. The current system of health facility assessments is seen as a tick-box exercise or a short-term hurdle to overcome to please management or funders. 

False compliance continues to lead to gaps in care and even when health facilities receive high ratings, the experience of patients does not bear this out. The cost of failing to address this is high.

Assessments lack objectivity

A critical study from the University of KwaZulu-Natal published in the journal Curationis found that among the many challenges facing the healthcare system in South Africa, the lack of objectivity in health facility assessments is one reason millions still experience preventable harm every day due to poor health services. 

Even with these dubious attempts at increasing scores, only a third of provinces meet the scores necessary to qualify for support. In 2018, 47% of sites accessed by the Office of Health Standards Compliance were deemed compliant. In the 2018/19 financial year, the office released an annual inspection report in which it stated that only 137 out of the 730 (18.7%) health facilities assessed in South Africa were compliant. Interestingly, the same listed health facilities that were not compliant with the National Core Standards have received awards in their Ideal Clinic assessments. 

A comparison of the various assessment outcomes is not reviewed by the Office of Health Standards Compliance or the Department of Health and the question remains how one site could be both compliant and not compliant in the same period. Over the three years (2019 to 2021), the government allocated R19.2-billion to improve facilities and an additional R4.3-billion via the National Health Insurance Fund, but these funds remain largely untouched and may even create a further perverse incentive for manipulating assessment outcomes.

We must ensure that quality services and lifesaving facilities are available to communities and that compliance assessments are done with integrity and without bias. That means ensuring more accountability in peer and self-assessments, by including external verification and transparent communication of findings to communities. These external assessments from unrelated entities ensure the findings are correct and provide training to peer assessors to ensure consistency. 

An ‘obvious solution’

A way forward could be right in front of our eyes.

Existing mechanisms such as health committees can play an instrumental role in assessments and ensure the oversight, assurance and objectivity necessary to save lives. These bodies are legally appointed by the MECs of health in provinces to strengthen the link between the community and the health facility. Committee members from the community should be empowered to act as the voice of the community, which is sorely missing in the assessment process.  

Of course, peer assessments can be a powerful tool — they promote opportunities for learning and remove the power dynamic present with external assessors, and they can foster trust between nursing management across facilities. This must not be lost. But the truth remains that the peer assessment on its own promotes bias and has led to a competitive culture where gaining a positive ranking is more important than community needs.

Ratings are linked to the status of the facility management and staff; it is recognised through internal communications channels and rewarded with a shiny accolade. All of this pushes facility staff to bend the truth and paint a picture that all is well when it truly is not. 

Very often, these assessments are not worth the time, effort or resources afforded them and do a disservice to staff and patients alike. As Covid-19 continues to challenge us to do more and do better, we have an opportunity to engage communities in this critical process through the health committees already in place. Given the right authority, we can equip them to hold health facilities accountable, to identify gaps honestly so we can address them, and ensure assessments do what they were meant to do: protect communities and give them a true sense of security. DM/MC

This article was first published in Spotlight.