SPEECH BY THE DIRECTOR-GENERAL OF THE DEPARTMENT OF HEALTH MS MP MATSOSO AT THE SAFECARE CONFERENCE..CAPE TOWN

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1 SPEECH BY THE DIRECTOR-GENERAL OF THE DEPARTMENT OF HEALTH MS MP MATSOSO AT THE SAFECARE CONFERENCE..CAPE TOWN Programme Director Colleagues from provincial health departments represented here Dr Carmen Audera-Lopez representing the World Health Organisation COHSASA Board members present here this morning Representatives of the industry Distinguished guests Ladies and gentlemen. Firstly, I would like to extend a warm South African welcome to our international (and South African) guests at this Launch Conference. I trust that your stay here will be fruitful, and I also hope that you will enjoy a little of our hospitality and natural beauty. Let me point out that I am standing here this morning representing the Director- General of the Department of Health Ms Precious Matsoso who could not be with us this morning owing to competing pressures. We are honoured to be hosting the launch of this exciting initiative and would like to also be able to learn from it and hopefully contribute to its goal of improving healthcare delivery. I note that it is especially directed at resource-restricted countries however I have learned that this is often a relative term, as many South Africans would tell you they consider themselves resource-restricted also, although this depends on who they are comparing themselves to! One of the themes we use to characterize our programme to improve quality of care in South Africa is getting the best possible results out of available resources and I think that is what any initiative such as this needs to help us to achieve. 1

2 I wanted to give you a bit of background to our own programme, in the hope that this will be of assistance in your deliberations here. South Africa has indeed achieved major advances in terms of access and equity when compared to the situation we inherited from apartheid, however our outcomes are very poor relative to the inputs we invest we are getting poor value for money. Part of the problem is that of the continued inequities in resources between public and private sectors and between urban and rural areas; as well as a major difference between resources and efforts going to hospitals compared to those going to primary health care. However this is not the whole problem; and we are asking ourselves whether we are indeed getting the best results out of our available resources. Our government remains extremely concerned at the continued dissatisfaction expressed by the public and our patients, who complain that staff are rude and uncaring, that our hospitals and clinics are dirty and unsafe, that patients have to wait for hours in long queues even if they are seriously ill and may then be turned away without receiving the medicines or treatment they need. Many studies and reports tells us that we have excellent policies and guidelines but we don t implement them neither at the level of management nor even at the level of patient care. Improving the quality of care has been a priority of ours for many years. South Africa has produced a Patient Rights Charter; national policies for Quality care, Infection Control and the management of complaints; and a large number of standards and guidelines from key health programmes to management functions. There have been significant efforts to define standards, to assess compliance, and to assist in improvements and programmes have been implemented (for instance by COHSASA who are one of our hosts today). The results of these efforts can be seen in the specific areas where support and resources have been poured in. 2

3 It is fair to say however that the problem of poor quality, poor reliability in following best practices, and lack of accountability for poor results (or of recognition for good ones), remains. This lack of accountability in our system for the provision of quality care is a significant challenge. We recognised some time ago that the multiplicity of standards and guidelines, all set by different entities or units or programmes, linked to the absence of a uniform, credible and legitimate way of measuring performance or investigating a problem, meant that it was not possible to hold managers to account. In a complex system such as health care, we could not benchmark establishments against each other as there were so many factors to be taken into account. But without this, even with good will, it is not easy to know whether your best efforts are indeed getting the best possible results in the circumstances. In addition, with responsibility shared among many different people at different levels of the system, it is difficult to decide who to hold accountable. And lastly, when there are no consequences where management is found wanting, why should managers make an added effort? Even where clinical care does not follow accepted practice or is frankly inadequate, it is always so easy to argue that someone else is at fault. The opposite is equally true are the many healthcare workers and managers who give of their best every day recognised for this? We have responded to this through a number of different mechanisms. We have done a lot of introspection over the past 2 years and have developed a new approach for the health sector as part of our government s determination to improve our results and our outcomes generally. Our Minister has negotiated and signed a detailed plan or Service Delivery Agreement for the health sector which reflects our commitment to improve the health status of our mothers and children, and to improve life expectancy through dealing proactively with the critical areas of HIV/AIDS, TB and chronic non-communicable diseases. We recognise however that this will only be possible if we improve the effectiveness of our 3

4 health system generally, as this is our vehicle for delivery of improved health care and results. We are investing a lot of time in improving and aligning our planning, management and development activities in the areas of human resources, financial management, infrastructure and equipment. Our intention to improve equity in access to quality care is reflected in our move towards national health insurance, while a major effort is also being put into re-engineering the health system as a whole towards a more preventive and primary health care approach, one that specifically involves communities in the design and the delivery of services and in the essential changes in behavior needed to improve health. Today however we are talking about another of these critical initiatives towards re-alignment and improved effectiveness of the health system, namely that of improved quality. After a long and consultative process, we have published a set of National core standards for health establishments in South Africa. This captures in one place the regulations, policies, guidelines and protocols that are already approved, that already guide our system. Because they reflect existing policies, they do not involve added responsibilities and it is reasonable to assess our managers against them, and reasonable to expect that they should be compliant. This set of standards does not attempt to replace the many excellent and detailed sets of standards that already exist, but to serve rather as a screening tool to identify where in fact the end result or outcome is problematic and needs further action. As such and in response to our managers feedback over the last few years, we have also invested a major effort to make the standards (and the tools for measurement) output-focused rather than merely listing a required set of inputs be they staffing, protocols or committees. We have therefore deliberately tried wherever possible to specify and measure whether the inputs result in the 4

5 intended result that is, whether they are implemented and whether there is evidence to show this. Such a policy tool requires a means to measure the level of compliance. A set of measurement tools has also been developed to measure and rate the level of compliance with these standards. As part of our routine information system this is available to all our managers and is already in use across the country as a tool for self-assessment and improvement within our public health establishments. The efforts to ensure that our public health establishments are in fact compliant are drawing on a wide range of different improvement approaches and methods that we know are needed to actually close the policy-implementation gap; and I am sure we will learn of more approaches during this conference. An interesting finding that is already apparent and which I am sure all of you as experts in the field are only too well aware of, is that over half of the compliance gaps identified are able to be solved at the level of the facility itself, without requiring any further intervention or funding. Although it is essential to improve health system effectiveness and quality, we recognise that our core business is caring for patients and communities. The flouting of policies, protocols and guidelines by our health professionals has contributed to the poor outcomes we see in our establishments. The high patient load relative to staffing in many establishments has been used as a reason for the decline in safety standards of care. However, the absence of clear clinical and corporate governance has perpetuated the sad state that we find our health system in, and this is often a weakness of leadership and ethics, not merely of staffing ratios. Recognising this, South Africa is planning to reinforce clinical governance at all levels of care as this would go a long way towards creating an environment where safety practice flourishes and risks are identified and mitigated. You ask how? 5

6 Through defining the roles and responsibilities of the members of the clinical team, and measuring their outcomes, we intend to improve ownership and accountability for all actions by individuals within the collective. In creating a safety culture, we will be encouraging reporting and requiring team discussion of errors or risky situations, while reviewing our systems and procedures. Part of this shared responsibility and information sharing will include regular incident review, investigation and reporting, as a tool for improving our services both locally and more widely. While we hope and expect that health professionals will take responsibility for reinforcing the ethical standards that society expects of them, the knowledge that they may also be subject to an external investigation which can identify clinical failings but also system failings, will we hope serve as an added incentive. We have taken these policy and technical responses several steps further however. As we all know, it is when policies and guidelines are reflected in resource allocations and ultimately in the law, that change happens. I know that you will be hearing from a number of different experiences in other countries about how to take forward efforts to improve quality of care. You will also be hearing about the serious commitment of the South African government to improving equitable access to quality care by changing our financing mechanism through the introduction of national health insurance... In order to inform our planning for the future, we have already started to audit our current situation (our baseline) in relation to a number of key inputs (staff, buildings, equipment, service package) as well as the most critical aspects of quality care. We have published for comment a National Health Amendment Bill which would establish an independent public entity (called the Office of Health Standards Compliance ) reporting directly to the Minster of Health, that will combine the 6

7 functions of an Inspectorate of establishments, health care providers and agencies with an Ombuds office that will investigate serious complaints against the health system and system barriers to the provision of safe and quality care by health professionals. An early warning system is envisaged, that will receive regular information on a limited set of indicators of risk or sentinel events that might lead to an ad hoc inspection or investigation. The Bill proposes that this Office will also advise the Minister on prescribed norms and standards for the national health system, and on approaches to ensuring quality care; and will monitor and evaluate quality and health outcomes. It makes provision for penalties to be applied in the case of violations or of non-compliance. Regulations to give effect to the Amendment Act once promulgated will then be published for comment. A key concern is strengthening the hand (and voice) of the patient and we intend to bring together our patients, their families and communities; as well as our health professionals and health workers, to facilitate a discussion of safe and acceptable care for patients. This is also important in order to make sure that such discussions then inform all aspects of the work of the independent Office. A further measure we have taken is financial. The Budget speech of the Minister of Finance two weeks ago, mentioned the funds set aside to establish this Office of Health Standards Compliance, but also significant funding to be made available over the next 3 years in order to assist our public health establishments to meet the standards. This shows a serious commitment indeed. In conclusion, I want to recognise that regulation and policy initiatives, benchmarking and certification, investigations and reports, will only be effective if they reflect and guide the values and practice of our professionals, our staff and managers. The Minister of Health and his provincial counterparts have all made clear their commitment to improving the quality of care we provide and thereby the kinds of results we can achieve and level of satisfaction expressed by our 7

8 users. We wish as a country to make poor care and unsafe practices unacceptable through re-activating, recognising and praising the commitment of our professionals and staff while also holding management and those who transgress to account. I am sure this Conference shares this view. I thank you. 8