Healthcare Service delivery efficiency; performance of gauteng hospitals

HEALTHCARE SERVICE DELIVERY EFFICIENCY: PERFORMANCE OF GAUTENG HOSPITALS

Nwauka Oliver Ibewuike

A project report submitted in partial fulfilment of the requirements for the degree of

Master of Engineering (MEM)

In the

GRADUATE SCHOOL OF TECHNOLOGY MANAGEMENT, FACULTY OF ENGINEERING, BUILT ENVIRONMENT AND

INFORMATION TECHNOLOGY,UNIVERSITY OF PRETORIA

Supervisor

Dr Richard Weeks

21 October 2013

Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals

AbstractThere is a general perception that public healthcare service delivery is deteriorating severely, despite government commitments to change this. This dysfunction stems from the cumulative impact of burden of diseases, economic pressures, population surge, policy and strategy incoherence and managerial incompetence. The core objective of this qualitative research study therefore, is to gain insight into the cause-effects of this minimal performance, patients’ dissatisfaction and the waste of resources in Gauteng’s public healthcare sectors, with an intention to provide recommendations in resolving this crisis and to further research on this subject.

This exploratory study used Performance Assessment Tool for quality improvement in Hospitals (PATH) framework and Data Envelopment Analysis to evaluate the satisfaction levels, performance and technical efficiencies of public hospitals compared to the private sector.

The findings agree that the satisfaction of patients is poor, performance sub-minimal and technically inefficient and health outcomes unsatisfactory relative to private hospitals. Public healthcare patients’ service dissatisfaction level was 76% relative to private sector’s 8%. The efficiency constant returns to scale (CRS) were (40%), (63%) and (100%) respectively for district, regional and private hospitals while the corresponding variable returns to scale (VRS) were 41%, 84% and 100% with scale efficiency score of 97%, 75% and 100 % in that order. Health outcomes such as patients re-admission within a 28-day period recorded 20%, 21%, <5% for the district, regional and private hospitals respectively, and PHC health outcome (25%).

The lack of patient satisfaction, performance slack and inefficiency resulted partly from overall poor decision-making abilities on the use and allocation of resources and the lack of integrated information systems in the facilities.

Efficiency and performance remain functions of transformational changes involving leadership, policies, innovations and models of care in the health system. The reorientation of the system must include review of the funding system, remuneration of service providers, ownership of the healthcare delivery organisation and system accountability.

Keywords: Delivery, Diseases, Efficiency, Gauteng, HealthCare, Hospitals, Information, Patients, Performance, Private, Public, Satisfaction, Service, Innovation.

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Acknowledgements

Special thanks goes to the Almighty for the strength, sense of direction and his benevolent mercy for the successful completion of this task.

My immeasurable gratitude goes to Mary Jane, my lovable wife for her support, love, and encouragement especially during the course of this work. To Craig, Marlene and Christine-Pearl, I remain grateful for your understanding and patience during the course of this work.

My mentor, Dr Richard Weeks, I remain grateful for your guidance, all round technical assistance, the sparing of your precious time for me and being compassionate throughout this period.

This research could have been unsuccessful, if it had not been for the tremendous assistance of Emrouznejad A. (PhD) of Aston University, United Kingdom, who willingly released his various published articles on technical efficiency in sub-Saharan Africa, with such short notice; C.W Folcher (PhD) for her inevitable role in ensuring that the research was approved by the private hospital.

Very special thanks goes to groups, individuals especially the staff, management of the Gauteng Provincial Department of Health, and the Johannesburg health district for their permission to use their facilities.

To doctors C. Kalu, M. M Modise and V. Molepe your assistance during the course of this research has been invaluable, thank you.

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Table of Contents

Chapter 1: Background to the Research Study......................................................1

1.1. Introduction....................................................................................................11.2. Rationale of the Research.............................................................................21.3. Problem Statement........................................................................................41.4. Importance of the Problem............................................................................41.5. Research Objectives.....................................................................................41.6. Limitations and Assumptions of the Research...............................................51.7. Conclusion.....................................................................................................5

Chapter 2: Review of Literature................................................................................6

2.1. Introduction....................................................................................................62.2 Health Review...............................................................................................6

2.2.1 Demographics........................................................................................62.2.2 Gauteng Healthcare Overview...............................................................82.2.3 Health Assessment................................................................................9

2.3 Health Strategies Review............................................................................122.4 Human Resources.......................................................................................152.5 Health Expenditure......................................................................................152.6 Healthcare Service Performance.................................................................172.7 Healthcare Service Satisfaction...................................................................182.8 Hospitals Efficiency in Gauteng...................................................................192.9 Gauteng Public and Private Healthcare Service Overlaps..........................202.10 Conclusion...................................................................................................21

Chapter 3: Conceptual Theories and Performance Models.................................22

3.1. Introduction..................................................................................................223.2. Healthcare System and Governance Concept............................................223.3. Hospital Levels and Service Structure.........................................................24

3.3.1. Primary Healthcare (PHC)....................................................................243.3.2. Hospital................................................................................................26

3.4. Healthcare Technology Innovation Concept................................................283.4.1. Integration of Health Information Systems...........................................303.4.2. Healthcare Innovation Conceptual Framework....................................31

3.5. Performance Assessment Framework........................................................333.5.1. Outcome Based Performance Assessment Framework.......................333.5.2. Performance Assessment Tool for quality improvement in Hospitals

Model (PATH)……………………………………………………………….343.6. Healthcare Service Delivery Concept..........................................................37

3.6.1. Service Delivery Models.......................................................................40

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3.7. Healthcare Efficiency Concept....................................................................423.7.1. Related Efficiency Terms.....................................................................443.7.2. Application of Data Envelopment Analysis (DEA)................................453.7.3. DEA Limitations....................................................................................48

3.8. Conclusion...................................................................................................48

Chapter 4: Research Design and Methodology....................................................49

4.1. Introduction..................................................................................................494.2. Qualitative Research...................................................................................494.3. Qualitative Research Methods....................................................................504.4. Advantages of Qualitative Research...........................................................514.5. Basics of the research.................................................................................524.6. Research Design.........................................................................................52

4.6.1. Research Method.................................................................................534.6.2. Purpose and conceptual context..........................................................534.6.3. Validity..................................................................................................55

4.7. Conclusion...................................................................................................56

Chapter 5: Results...................................................................................................57

5.1. Introduction..................................................................................................575.2. Demographics Data.....................................................................................575.3. Service Indicators........................................................................................59

5.3.1. Nature of Service and Patient centeredness (Satisfaction)..................595.3.2. Service Availability and Resource Allocation........................................605.3.3. Facility Capacity and Service Utilisation...............................................615.3.4. Information Systems and Technology Innovation.................................635.3.5. Governance (Leadership).....................................................................655.3.6. Government Policies and Strategies....................................................665.3.7. Health Outcomes..................................................................................67

5.4. Result Analysis............................................................................................685.4.1. Service Gaps between Public and Private Healthcare Sectors............71

5.5. Conclusion...................................................................................................72

Chapter 6: Conclusions and Recommendations..................................................73

6.1. Introduction..................................................................................................736.2. Performance Recommendations.................................................................736.3. Recommendations for Further Research....................................................786.4. Conclusion...................................................................................................79

References...............................................................................................................80

Appendices..............................................................................................................89

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List of FiguresFigure 2.1: Gauteng Provincial Health Services Structure...........................................8Figure 2.2: Trends in South African Mortality.............................................................11Figure3.1: Concept of Health System and Public Health Boundaries........................23Figure 3.2: Health Monitoring Committees................................................................23Figure 3.3: South African Health Delivery System.....................................................25Figure 3.4: Types of Healthcare Innovation...............................................................29Figure 3.5: Health Information Exchange..................................................................30Figure 3.6 How increasing value increases information intensity.............................31Figure 3.7: Healthcare Innovation Framework...........................................................32Figure 3.8: A Win-Win Innovative Transformation.....................................................32Figure 3.9: Performance Framework Showing the Health Outcomes........................34Figure 3.10: PATH Conceptual Model.......................................................................35Figure 3.11: Performance and Quality Measures (Triad Interactions).......................36Figure 3.12: Determinants of Performance................................................................37Figure 3.13: Systematic View of Service Delivery.....................................................38Figure 3.14: Changing Value Dimensions.................................................................39Figure3.15: Citizen Health Decision Approach.........................................................39Figure 3.16: Six Domains of Performance Interventions............................................42Figure 3.17: Topology and Types of Efficiency..........................................................43Figure 3.18: Determination of Hospital Efficiency Using DEA Analysis.....................46Figure 3.19: Hypothetical Illustration of Technical Efficiency.....................................47Figure 4.1: Research Methods...................................................................................49Figure 4.2: Qualitative Research Methods.................................................................50Figure 4.3: Interactive Model of Research Design.....................................................52Figure 5.1: Production Possibility Frontiers indicating the Efficiency Trend Using the Input/Output mix of the Hospitals...............................................................................70

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List of TablesTable 2.1: Gauteng Public Hospitals / Levels..............................................................7Table 2.2: Demographic Indicators of Gauteng Province (Extract)..............................8Table 2.3: Past 15 years Accomplishments and Shortcomings of South African Health.......................................................................................................................... 9Table 2.4 South African Health Review for First Quarter 2011..................................10Table 2.5 Provincial Health Expenditure (Rands in millions).....................................16Table 3.1: Stakeholders Needs, Wants and expectations.........................................28Table 3.2: Key Hospital Performance Dimensions....................................................35Table 3.3: Evolution of Service Delivery Models.......................................................40Table 3.4: Service Delivery Models with Improved Competencies............................41Table 3.5: DEA Analysis using a hypothetical illustration..........................................47Table 5.1: Hospital Variables.....................................................................................69Table 5.2: Efficiency Ratios of the Hospitals..............................................................70Table 6.1: Performance Recommendations.............................................................73

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List of Acronyms/Definitions/Abbreviations

AIDS Acquired Immune Deficiency Syndrome CHC Community Health Centres DEA Data Envelopment Analysis DOH Department of Health

GEMS Government Employees Medical Scheme HIV Human Immunodeficiency Virus JSE Johannesburg Stock Exchange MCH Mother and Child Healthcare MDG Millennium Development Goal MSTF Medium Term Strategic Framework NHA National Health Act NHI National Health Insurance NHS National Health System NHP National Health Plan NSDA Negotiated Service Delivery Agreement PHC Primary Health Care SADI South African Development Index SAHI South African Health Index

SADS South African Demographic and Health Survey WHO World Health Organization VCT Voluntary Counselling Test

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Chapter 1: Background to the research study

Chapter 1: Background to the Research Study

1.1. Introduction

Efficient service delivery in public hospitals is not a concern to the patients and the community alone but also to the state. The healthcare sectors’ mandate is to develop, organise and deliver an integrated and comprehensive healthcare practise and service to match international norms, ethics and standards and to create values to meet patients and providers expectations, needs and levels of satisfaction (Lehohla, 2006:24; Soumya, Eckhard, Pomeroy & Rowan, 2009:9). To achieve this, the healthcare services focus on patient care and management of healthcare facilities for which mandates are derived from the South African Constitution, The National Health Act , provincial enactments and The Council for Health Services Accreditation of Southern Africa (Department of Health, 2005:76) and the Municipal Structure Act (Balfour, 2007:4).

Considerable pressure is on the available limited resources due to increased service demands from the public. Department of Health (2011:18), Zere, Tumuslime, Walker, Kirigia, Mwikisa, and Mbeeli (2010:10) argue that the shortages of healthcare resources resulted from macro-economic performance, budget cutbacks, population explosion, the AIDS pandemic and increasing incidence of injuries and diseases. These researchers agree that both internal forces and external factors marred efforts to achieve this, exerting pressure on the costly needed skill, materials and, technology. The bureaucratic procedures and management process worsened these problems, making it difficult for the workforce and medical expertise to function as a system, creating service gaps to favour the private sector in areas of patient satisfaction and resource emancipation for the stakeholders (Zere et al., 2010:10). The cause-effect of this shows South African hospitals consuming an average of 50-80% of resources that accounts for 11% of the overall budget of the government (Department of Health, 2005:4; Msimang, 2005:5; Zere et al., 2010:10). Of the 8.7% of the gross domestic product (GDP) allocated to health, the private sector utilizes 5.2%, this accounts for only 20% of the 50 million of the population, and the rest (3.5%) goes to the public sector that serves 80% of the population (Department of Health and Global Health, 2005:3; Gauteng Department of Health, 2011:21; Lehohla, 2006:5; Ngwenya, 2007:164).

This notwithstanding, the performance efficiency of the healthcare sector service delivery has been poor and is feared deteriorating with the rising demographic of ill-health in South Africa (Cullinan, 2006:2; Global Health, 2005:3; WHO, 2009:10).

Taylor (2009:1) in a report on “Healthcare Reform in South Africa” argues that poor

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health services is not entirely due to funding but also the result of cronyism, fraud, poor working conditions, low remunerations to professional staff, and appointment of unqualified managers. Information dispersion, ineffective communication and unstandardized protocol are evident in the public healthcare sector (Motsoaledi, 2011:7). Other influencing factors include the rapidly changing and complex technology, human development, policy regulations and global shift from process oriented to result oriented performance (Department of Health, 2005:76; Motsoaledi, 2011:7). In addition, the lack of integrated health information results in deficiencies in performance process causing long waiting times at the registration process (Global Health, 2005:3), hence several protests against the dissatisfaction of patients and service inefficiencies. These challenges, Motsoaledi (2010:2) warns cannot be minimized if no effective methods are devised to check, manage, monitor and control the use of resources especially in the areas of skill; technology; drug and finance; revalidation of health strategies and policies and review of health status with reduced political bureaucracies.

1.2. Rationale of the Research The rationale for this research study stems from a number of critical issues, namely:

The South African demographic and health survey shows that South Africans are not healthy (Day & Gray, 2011:7; Department of Health, 2005:9; Global Health, 2005:3; WHO, 2009:10) and South Africa ranks low in health sector performance compared to other developing and developed countries (Msimang, 2005:5).

The lack and denigration of skills in the country resulting from a shortage of health professionals and the problem of brain drain in all healthcare sectors is justified as a key cause of its minimal performance (Department of Health, 2011:18; Clarke, Schoeman & Friedman, 2007:1).

The Private sector is accessible to 20% of the population and consumes more than 60% of the healthcare budget (Ngwenya, 2007:164) employing more than 70% of health specialists (Lehohla, 2006:5).

The public sector faces the challenge of transformation and re-organisation, budget reform and enhancement of the quality of care and human resource management (Lehohla, 2006:24).

Social and cultural orientation and a change in lifestyle patterns could have influenced patients to have unrealistic expectations and hospitals to display unexpected service failures, which culminates in the perception of low healthcare service performance (Murray, 2008: 17).

A well performing health system, characterised by greater equitability,efficiency and sustainability of health service outputs delivers accessible, high

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quality and affordable curative and preventive services, (Soumya, et al., 2009:9).

Emphasis on the need for constant monitoring of hospital productivity,

necessitated by limited resources and unlimited health needs (Kirigia,

Emrouznejad, Cassoma, Zere & Barry, 2008:5). The need to adopt an outcome based approach to service delivery with a

focus on efficiency to achieve the Negotiated Service Delivery Agreement (NSDA) objectives (Motsoaledi, 2010:2).

The challenges facing the health sector being poor quality of services; poor equipment; procurement practices; inadequate skills mix; communication; knowledge and information access; population surge; several complaints; shortage of health workforce; use and allocation of limited resources and the spiraling cost of services (Motsoaledi, 2011:7).

The following narrative summarises a common incident in healthcare service delivery observed recently in one of the South African public hospitals:

“Joe, a 34 year old male with fee-for-service coverage suddenly developed pain on the on the left hand side of his chest. The pain was so severe that he requested the sister to call an ambulance that never arrived to take him to hospital. On getting to the hospital, the registration process took long, as there was only one frontline staff member serving many people in the queue. Meanwhile, Joe was still groaning in pain holding his left part of his chest.

At the casualty, a registered nurse next to Joe ignored to call the doctor or even care to assist Joe in the triage room. The non-responsiveness of the nurse worried other outpatients who drew her attention to Joe. Still enjoying the heater warmth, Joe’s sister persuaded her to call the casualty doctor for Joe, who was now lying on the floor. While the casualty doctor was still ascertaining why he was not notified early, Joe ‘crashed’ (died).”

The above narrative shows several healthcare service pitfalls such as a lack of responsiveness, timeliness of care, unreliability, non-accountability for the care of the patient and communication inadequacies from both ambulance units and the nursing staff. The shortage of staff and long waiting time at the registration process also complicated the incident and prevented the problem of myocardial infarction from being averted, which would have been possible with early intervention by the doctor. These challenges cannot be minimized, if no effective methods are devised to check, manage, monitor and control the use of resources especially in the areas of skill, technology, drug and finance. Strategies and policies need to be revalidated, the health status reviewed and political bureaucracies reduced.

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1.3. Problem Statement

According to “Healthcare in a Democratic South Africa” (Department of Health, 2005: 24) report, healthcare service delivery is a tenet based on the Batho Pele Principle, the Patients’ Rights Charter, the National Health Plan 2011, the (WHO) targets and the Millennium Development Goals’ (MDG) expectations. General opinions show that the demands on the health service system exceed service capacity that lead to the acclaimed service failure due to poor performance.

These issues and its preceding discussions led to a thought provoking statement to this exploratory research study:

Trying to get to the cause-effects of inefficiency prompted other challenging questions such as:

What performance and efficiency standards exist? What effective assessment methods are used? What service gaps exist between public and private hospitals?

1.4. Importance of the Problem

The impact of poor performance of the public health sector service delivery seen in the long waiting times, complaints, protests, rude and uncaring staff, waste of resources and medical errors have created great dissatisfaction effects amongst all stakeholders. This problem also created service gaps between the public and private healthcare facilities. Evaluating and assessing the health system on the needs of patients is of paramount importance to hospitals’ management, the government and to the patients, to ascertain the reasons for their loss of confidence in these public healthcare facilities. Motsoaledi (2011:10) insists that updating efficiency in the health system will also ensure that the delivery of healthcare services is planned, monitored and managed appropriately to ensure reduction of waste.

1.5. Research Objectives

The objectives of this research are formulated based on the identified healthcare problems in the preceding sections. The core objective of this qualitative research therefore, is

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The service performance efficiency of healthcare delivery in the state hospitals and clinics is sub-standard relative to private hospitals within the same demographic and geographic region.

To gain insight into the cause-effects of this minimal performance, patients’ dissatisfaction and the waste of resources in Gauteng public healthcare service sectors.

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The following subsidiary objectives stem to accomplish this research intent: To indicate the nature of service, patients’ satisfaction (centeredness) and

Performance level of Gauteng healthcare sectors. To indicate the extent, influence and the use of e-service and information

access in public healthcare facilities. To review the extent of service availability, facility capacity, resource

allocation, utilisation and the efficiency levels of the public healthcare sector. To indicate how governance influences healthcare service delivery and

effectively ensuring efficiency of the hospitals. To show how the implementation and usage of health policies and strategies

influence service delivery. To identify the service gaps existing between the private and the public

healthcare facilities. The aim of this research is not to identify individual failures, rather to use the

results as a guide to improve hospital performance in achieving the best possible healthcare service.

1.6. Limitations and Assumptions of the Research

The following issues and assumptions constrained this study: All hospitals in this survey are in the same geographical and demographic

area and the public hospitals obtained equal resource allocations relative to their levels.

Due to the complexity and multifactorial nature of efficiency in healthcare, service quality dimensions and performance assessments tool for quality improvement in hospitals (PATH) process dominated in the evaluation of patients’ satisfaction and the efficiency performance of the hospitals.

Time and resource constraints restricted this research to one primary healthcare clinic, two public hospitals (one at district level 1 and one regional hospital level 2) and one private hospital (benchmark) assumed to be on the same level 2 as the state regional hospital.

The absence of data on the prices of input limited this research to the measurement of technical efficiency.

1.7. Conclusion

The dilapidation of services in Gauteng public healthcare sector evident in patients’ dissatisfaction, despite the availability of limited resources prompted this research study to assess the extent of these performance crises in these healthcare facilities.

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Chapter 2: Review of Literature


2.1 Introduction

A healthy nation is a wealthy nation. Health is an important part of a country’s economy. According to Omachonu and Einspruch (2010:10), healthcare constitutes work done in the prevention, diagnosis, and the treatment of diseases, injury and other social impairments. Omachonu and Einspruch (2010:10) attest that health policies, cultural, political, human resources, information technology, organizational and other socio-economic conditions prevalent in the area influence access and utilisation of health, these factors intermingle to affect the service and delivery of healthcare.

Previous literature on the South African healthcare system exists; however, information on the comparative performance efficiency of the healthcare system of Gauteng hospitals is rarely available or non-existent. In 2000, Maseye, Kirigia, Emrouznejad, Sambo, Mounkaila, Chimfwembe and Okello (2006:475) conducted a similar research on 155 primary healthcare clinics (PHC) in Kwazulu Natal to investigate the technical efficiency of the public clinics. In the same report, Zere, Addison and McIntyre (2000) investigated 86 public hospitals in the Eastern Cape, Northern Cape and Western Cape for technical efficiency. The conclusion of the various results of the researchers shows that public hospitals in South Africa are relatively technically inefficient with a minimal patient satisfaction.

2.2 Health Review

This section highlights the Gauteng demographics, health overviews, health assessments, existing government strategies, and health policies. Also included in the review is the South African health status, healthcare expenditure, resources allocation and other influencing factors of the healthcare service delivery processes. 2.2.1 Demographics

The Gauteng province, according to Statistics SA, contributes 34% of the gross domestic product (GDP), has an unemployment rate of 25.6 %, with 97% of the 11.9-million ‘hospicentric’ population are habituated in urban areas (Lehohla, 2006:5). The report further states that the province considered as the smallest among the provinces, with three major urban areas namely Pretoria, Johannesburg/Soweto and the Vanderbijlpark Industrial Complex is bordered by the four (4) provinces of Limpopo, North West, Free State and Mpumalanga. Among its most important health institutions are Charlotte Maxeke Johannesburg Academic Hospital, Steve Biko Academic Hospital and The Medical University of South Africa plus numerous such

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health institutions as universities and nursing colleges (Gauteng Department of Health, 2011:1)

Table 2.1: Gauteng Public Hospitals / Levels

Source: Gauteng Department of Health, 2012:1.

Lehohla (2006:24) and Gauteng Health and Social Development (2011:1) further remark that the Gauteng statistics constitute twenty (20) community health centres (CHC) and over 200 private hospitals and clinics. These researchers also indicated the provisional baseline waiting times in CHC to be 88-200 minutes, accident and emergency unit for priority patients 2 and 3 (48-180 minutes) and pharmacy (50-120 minutes).

The Gauteng health demographics in table 2.2 indicates a proportional increase in the rate of disease infections with a greater percentage of the population in the public sector affected due to the pronounced social variance in this province. Day and Gray (2010:227) report that adults and children on antiretroviral treatment were on the increase from 2005, with an increased rate of maternal and infant mortality.

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Table 2.2: Demographic Indicators of Gauteng Province (Extract)

Source: Day and Gray, 2010:227.

2.2.2 Gauteng Healthcare Overview

Gauteng health service structure (figure 2.1) allows for efficient communication, encourages departments and groups within the health unit to work together, establishing a hierarchy of responsibility that allows the system to grow in a controlled manner (Gauteng Department of Health and Social Development, 2011:15).

Figure 2.1: Gauteng Provincial Health Services Structure

Source: Gauteng Department of Health and Social Development, 2011:15.

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Gauteng healthcare service delivery has the sole aim of providing well-deserved healthcare services to its stakeholders. The various units of the provincial healthcare management, information technology, operations, human resources, corporate services, strategy and policy are distinctively structured to achieve this objective (Gauteng Department of Health and Social Development, 2011:15). According to Couper, de Villiers and Sondzaba (2010:120), the major emphasis centres on primary services of sustainability, free health care services for children under the age of six and pregnant women, abortion policies, and free access to primary healthcare.

These efforts and accomplishments (table 2.3) notwithstanding, great challenges persist in the area of rationalization of tertiary Services in the Gauteng health system.

Table 2.3: Past 15 years Accomplishments and Shortcomings of South African Health

Source: Harrison, 2009:2.

Couper et al. (2010:121) argue that the slow pace to distinguish the academic, central and regional hospitals in their services exerts pressure on the provincial and regional hospitals because patients believe that great satisfaction only comes from hospitals higher in service level. Couper et al. (2010:121) continues that attracting health professionals constitutes one of the biggest problems in government hospitals, constrained by a limited budget and improper alignment with the redistribution and rehabilitation grants, notwithstanding the WHO recommendation (2004).

2.2.3 Health Assessment

The unimpressive health outcome demands a huge emphasis to improve health

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System performance. The first quarter 2011 report (table 2.4) of The South Africa Development Index, published by The South African Institute of Race Relations (2011:4) on a health status survey of the Gauteng province shows an increment on HIV infections and infant mortality with a decline in female life expectancy.

Recent figures show that the South African population approximates to 50 million with increased male life expectancy and a drop in female life expectancy with immunization and HIV infection rates having increased (Department of Health, 2005:9; Global Health, 2005:3; South African Institute of Race Relations, 2011:4 & World Health Organisation, 2009:10).

Table 2.0.4 South African Health Review for First Quarter 2011

Source: South African Institute of Race Relations, 2011:4.

A similar result presented by Day and Gray (2011:5) shows that hospital bed density stands at 2.84 beds /1000 population and HIV/AIDS related deaths have increased. Day and Gray (2011:7) further remark that among these, Gauteng represented 19.4% of the SA population with HIV/AIDS, lamenting that HIV/AIDS is the largest single cause of death amounting to 33% of all deaths in the province. Day and Gray (2010:242) and Harrison (2009:11) agree that there is little detectable change in TB incidence, and cure. Bradshaw, Pillay-Van Wyk, Laubscher, Nojilana, Groenewald, Nannan, Metcalf (2010:3) warn that 44% of all premature deaths in Sub-Saharan Africa come from AIDS/HIV related diseases, infections and parasitic diseases were prominent in the district and regional level data with adult mortality getting less attention in areas of policy, resources and monitoring effort (Day & Gray, 2010:230; Lehohla, 2006:4).

The WHO (2010:9), Department of Health (2005:9) and Global Health (2005:3)

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reason with the South African Development index report that South Africans are not healthy. Overlooking such factors is disastrous; however, tracking number of deaths (figure 2.2) and births improves the process (Day & Gray, 2010:230; Lehohla, 2006:4).

Trend in Mortality Rate Adult mortality gets less attention in areas of policy, resources and monitoring effort(Day & Gray, 2010:230; Lehohla, 2006:4). These researchers warn that deaths are on the increase in sub-Saharan Africa because of the HIV pandemic, adding that 44% of all premature deaths come from AIDS, Syphilis, Homicide, Tuberculosis and related injuries. Day and Gray (2010:230) affirm that certain infections and parasitic diseases were prominent in the district level data as the main major causes of death.

Figure 2.2: Trends in South African Mortality

Source: Bradshaw et al., 2010:3.

Historical Overview of TB and HIV/AIDSTB/HIV related illness is known to be a major cause of death in the country. The public health sector response to this trend is rather slow. Kautzky and Tollman (2008:2) contend that HIV/AIDS exerts immense strain on all aspects of the health system, citing that during Nelson Mandela’s regime, HIV was never a priority; Thabo Mbeki’s regime was where the leadership oversight progressed to unqualified denial that led to confusion, programming delays and seriously comprising governmental authority. Kautzky and Tollman (2008:22) conclude that the aftermath was a worsening in health indicators, escalating virus transmission and decline in life expectancy.

The Department of Health (2011:8) in The South African National Health Insurance (NHI) policy paper reveals that the South African population constitutes 0.7% of the

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world population and carries 17% of the entire AIDS infection in the world (23 times the Global average), with a TB co-infection record of 73% (highest in the world). This terrific HIV surge, Harrison (2009:20) remarks created an unexpected demand on anti-retroviral treatment (ART). Negligence or not taking into cognisance of this vital information immensely affected the service delivery process at the PHC level.

Within these periods of HIV treatment upheaval, much data on patients were lost especially those not registered or who died after commencement of treatment (Harrison, 2009:20). The current information when compared to MDG 2015 targets seems unrealistic to achieve. The infant mortality rate, maternal mortality rate and life expectancy figures of 2010 are improving at a ‘snail’ speed (Day & Gray, 2010:213).

Day and Gray (2010:242) in a paper titled “Health and Related Indicators in South Africa” point out that there is little detectable change in TB incidence, and cure, concuring with figure 2.3 presented by Harrison (2009:11) on the steady increase rate of TB transmissions.

Lancet (2011:375) estimates there to be 1.37 million incident cases of HIV positive TB, attributing the causes of these deaths to the complications of multi-drug resistant (MDR) and extended drug resistant (XDR) viruses. Despite such invigorating actions as ‘Stop TB Strategy’, intensification of research towards innovation, development and enforcement of bold health system policies and the establishment of links between the broader development agenda and its promotion by the government on this pandemic, no discernible improvement is accomplished. These numbers are frightening, considering the rate of infection of TB and HIV, life expectancy reduction, high maternal and infant mortality ratios despite the efforts of the Government and other healthcare stakeholders in curbing this menace of dreaded burden of diseases in the country. The increase on the cure rate evident in the successful completion rate is just a small-strived effort on the actual burden of diseases with the expectation that by 2014, it will increase to 85%, according to the South African Health Review report (Day & Gray, 2012:242). The data shows the impact of TB measurement, access barriers, communication, social mobilization, contact tracing, recording and other diagnostic tools, which immensely affect the service delivery process.

2.3 Healthcare Strategies and Policies Review

Various policies, statutes and legislations govern healthcare service delivery both locally and globally. In South Africa, most of these laws fall within the portfolio of the Department of Health (Pearman, 2011:115). Pearman points out that the national and provincial healthcare systems replaced the Health Act No 63 of 1977 with Act No. 61 of 2003, previously assigned to provincial government legislation that gives

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the national government a supervisory power to ensure the implementation of the new law. Section 7(2), section 27 and section 36 of the constitution (referred to as the Bill of Rights) focuses on fairness (equity), responsiveness, and access to quality of health meets the demands of the South African health needs.

The WHO (2010:9) regrets that efforts toward health systems improvement to meet with the millennium Development Goals (MDG) in South Africa is unreasonably slow especially in addressing the complexity of burden of diseases, access and affordability and ensuring responsiveness to population health needs. Taking urgent and strict procedures in observing and following the relevant issues is extremely important, the WHO advises.

The integration of local and provincial health systems was fraught with unexpected obstacles. More problematic was the employment of health personnel under a single authority, the effect of uniform salary schedules and conditions of employment caused by slower restructuring of local and provincial governments, concerning comprehensive health service provision (Department of Health, 2005:6), this reform process becomes an end in itself and not a means to improve health system performance (Arries & Newman, 2008:3).

According to Marks, Hunter and Alderslade (2011:24), patients’ information and records either are in files or still not properly documented. Challenges counteringaccess to patient data, safeguarding patient privacy, safe and effective data sharing, results in governance system slack (Department of Health, 2005:6). Mbananga, Madele and Becker (2002:14) contend that electronic transfer of information like prescriptions from one hospital or service provider to another is not in existence. Marks et al. (2011:24) and Mbanaga et al. (2002:14) insist that the delay in improper implementation of hospital information systems negatively affects patient information transfer within and between hospitals. This affects the delivery of services across the department, especially in the re-engineering and standardization of patient administration and related procedures throughout the hospitals, hence, eluding the information dispersion necessary for performance evaluations and health care audits. Mbananga et al. (2002:18) and Shih and Schoenbaun (2008:xii) warn that the policy on decentralization of hospitals, and the slow pace in the governance system may affect the decision-making due to unavailability of integrated management information. Shih and Schoenbaun (2008: xii) advise that government as a matter of urgency shall increase its efforts in establishing care co-ordination networks, care management services, and after hour coverage and performance.

Lorenzo, Ronquilo, Nodora and Silva (2007:4) highlight another major weakness inthe health system as the workforce’s lack of monitoring and evaluation of information.Shih and Schoenbaun (2008: xii) reveal that current training programs of health

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professionals do not adequately prepare them as a team based for the huge demand intensive labour healthcare service, these researchers insist that the training must provide system-based skills and competencies. According to Lorenzo et al. (2007:11), lack and/or shortage of proper training system, including human resources and use of proper equipment has affected the actualization of MDG targets, child survival and health outcomes. Appropriate training and training equipment, distribution and support of health professionals have a severe implication on the management as well as technical emphasis on resource management. Lorenzo et al. (2007:12) and Taylor (2009:1) affirm that low remuneration of health professionals and a lack of policy guidelines on standardised wage rates affect health outcomes.

According to Day and Gray (2010:311), the survey of PHC facilities conducted in2003, in 31 health facilities with the focus on patient safety, cleanliness, infection control, staff attitudes, waiting times and drug supply, found that half of the facilities were in bad condition because of negligence, lack of maintenance and even vandalism and theft. Day and Gray (2010:311) further reveal other key aspects influencing service delivery as insufficient resources, existence of cultural practices (opposition to clinical immunization, enemas and use of traditional medicine) and infrastructural problems.

The high value attached by healthcare givers to diagnosis and treatment when the patient is ill makes delivery costs highly unaffordable and unattainable in the restoration to full pre-disease health for chronic illnesses. However, proactive care strategies, which focus on personalized prevention production, early detection, treatment and disease management creates a healthier population and at a lower cost (Adams, Baker, Boroch, Knecht, Mounib & Stuart, 2008:14) through the introduction of a National Health Insurance (NHI).

According to the Department of Health (2011:18), the NHI strategy, rooted in the South African bill of rights, in adherence to the WHO performance recommendations is established as an avenue to alleviate the needs and wants of the huge insatiable demands of the public. Based on the principle of affordability, equity, right to access, social solidarity, effectiveness, efficiency and appropriateness of care, its major objective is to procure services, mobilize and control key financial resources in order to eradicate the weak purchasing power, which is a major limitation of some of the medical schemes that results in spiral costs. Other achievable targets are to provide and improve access to quality health services for all South Africans and to achieve social solidarity and equity through the creation of a single fund (Department of Health, 2011:18).

There are clear indications that government is failing in all efforts to curb theinadequacies in human resources, governance, burden of diseases, and excessive

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expenditure justified by these causative agents that has resulted in poor healthcare service outcomes. In lieu of this, government saw the need to transform the health sector in not only finance, and human resources but to strengthen the plan, information management, service provision and the total overhaul of management systems (Department of Health, 2011:6).

2.4 Human Resources

There is a dearth of information in this area for private hospitals. According to the Department of Health and Social Development (2012:1), in 2010 the medical workforce was estimated to be 40,000 nurses, 6775 medical practitioners and 5410 medical specialists. The fact is that shortages of nurses and doctors affect health services adversely, and as such, South Africa’s health crisis will continue to surge. The growth rate according to The Health Report (2009) considering human resource health (HRH) showed an annual growth rate of 1.8% (nurses), pharmacist (2.3%) and medical practitioners (2.5%) (Department of Health & Social Development, 2012:1).

Arries and Newman (2008:4) claim that South African health institutions struggle to fill more than 60% of existing posts, yet over 4000 vacancies exist for general practitioners, 32000 for nurses (all provinces) and 31% of other medical positions remain unfilled nationally partly due to emigration and policy bureaucracies. Over 63% of available general practitioners work in the private sector, which is nearly twice as many as in the public sector, between 30-50% of South African medical graduates migrates each year.

The emigration of essential medical staff undermines the cultural point of care especially in PHC service provision (Kautzky & Tollman, 2008:24). The researchers point out that, the scarce skills complicated by a decrease in enrolment of nurses in government institutions, is a consequence of a lack of planning to increase capability of medical institutions. The WHO (2010:319) suggests that improved retention increases access to health workers in rural areas. It further recommends financial incentives, personal and professional support, regulatory mechanisms and focuses on education as a means to make a reasonable change.

2.5 Health Expenditure

According to Day and Gray (2010:9), the WHO recommends that on the average, acountry should use at least 5% of its GDP on healthcare, but surprisingly South Africa spends 8.5% of its GDP on health, far exceeding the WHO recommendation, Nonetheless, the health outcomes remain an illusion. For instance, over 70% of theatre times at the Charlotte Maxeke Johannesburg Academic Hospital with trauma

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cases require a large supply of blood, the cost of which escalates between 15-35% while the budget only increases at the rate of 5% (Department of Health, 2008:55).

Most of the expenditure on health ( in table 2.5) goes to the district health system. However, the private sector absorbs 61% of national health expenditure in providing medical care to approximately nine (9) million people and the rest 40% goes to the public sector that provides medical care to 41 million (Kautzky & Tollman, 2008:24; Ngwenya, 2007:164). In a report titled “Healthcare in a Democratic South Africa,” the Department of Health (2005:2) stated that the reality of dualism in healthcare delivery persisted with a significant private-for-profit sector alongside the public health sector.

Gauteng residents tend to be hospi-centric, bypassing clinics to either district, regional or tertiary hospitals, when clinics can conveniently resolve their cases. This leads to congestion in hospitals and wasteful use of resources when treated at a higher level (Gauteng Department of Health & Social Development, 2011:32).

Table 2.5 Provincial Health Expenditure (Rands in millions)

Source Gauteng Department of Health, 2009:8.

Before the reversed tax subsidy for private health care in 2006, the state spent moreper head on private health sector delivery than public (Ngwenya, 2007:164), thus attracted more health professionals to the private sector making the ratio of patients to health professionals lower in the private sector, (Kautzky & Tollman, 2008:24) conclude. McAuliffe (2004:2) remarks that the system must respond to people’s legitimate health expectations based on need and not on the ability to pay; and must ensure fair financial contribution for the users of the healthcare system.

The Gauteng Department of Health (2009:8) in a paper titled “Integrated SupportTeam,” reviewed health overspending and macro-assessment of public systems in South Africa. After an extensive investigation, it came up with a report that “bloated”

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bureaucracy, poor financial management and inadequate monitoring resulted in the poor value for money spent by the public healthcare sector. Harrison (2009:2) in his findings listed these shortcomings attributing it to a cause-effect of a lack of managerial accountability in the attainment of service related targets.

2.6 Healthcare Service Performance

The Department of Health (2005:8) and Msimang (2005:5) agree that South Africaranks low in healthcare system performance and that health worker’ training and supervision are not standardised and comprehensive. The dismal state, according to the Gauteng Department of Health (2009:3) included inequitable healthcare spending, poor leadership, accountability and fiscal discipline, limited child advocacy, poor performance in service delivery and an inability to translate policy to practice.

The Department of Health (2009:9) annual report states that various surveys and studies conducted on health facilities indicate inadequacies in affordability, access to facilities and quality of care in the public sector. According to this report, an assessment of 31 health facilities using the revised core standards (PATH framework) confirm that the facilities were in a bad condition due to poor maintenance, vandalism and theft. Over 59% of the province uses public hospitals, 25.3% (Private), while 33.85% never used the nearest facility citing excessive waiting times, 15.9% non-availability of medicines, 10.8% rude/uncaring staff as the reason. Reports on higher levels of satisfaction shows that in private healthcare facilities 92.4% of users were very satisfied with the services they received (Department of Health, 2009:9).

Day & Gray (2010:312) reveals that the NSDA estimated 87.5% (2009) of the public sector health users to increase to 90% in 2014/15, but highlighted the lack of affordable and accessible transport, particularly for the continuity of care and treatment of HIV and other chronic diseases. The report continues with The Human Science Resource Council’s household survey, which shows a high utilization of healthcare services of 90%. Those hospitalized for 6-9 days accounted for over 20% of this number, indicating a failure of the PHC system’s ability to prevent and adequately manage diseases (Day & Gray, 2010:312).

To achieve better equity to match the MDG 2015 target, Soumya et al. (2009:8) emphasises the importance of delivering an efficient and effective healthcare system especially in the three 3 aspects of health service priorities of access, quality and utilization. Shih & Schoenbaun (2008:1) affirm that several influencing factors affect these aspects of service delivery process in healthcare system, stating that information gaps in the paper medical records could cause a lack of care co-ordination and support. These researchers contend that 17.6 % of hospitalization,

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according to the study, resulted in re-admission within 30 days and of those, 75% is potentially preventable; far fewer hospitals provide a full care transition program. Medication and reconciliation often proves difficult because of a lack of co-ordination between the ambulance units and the hospital due to either a scarcity or the non-existence of electronic medical records (Shih & Schoenbaun, 2008:1).

Most public sector hospitals, Shih and Schoenbaun (2008:4) argue do not have a system in place to track and deliver appropriate care, and this results in the lack of a participatory role in achieving improvements in quality initiatives. In addition, the implementation of an electronic medical record system with disease registries, care reminders and clinical decision support has not been possible. Statistics show that it is difficult for 80 per cent of South Africans to get care during the night, weekends or holidays without going to the emergency room (Shih & Schoenbaun, 2008:4).

2.7 Healthcare Service Satisfaction

In a Statistics SA survey, Lehohla (2006:4) further indicates the usage of healthcare services; 59% (Public Clinics); 25.3% (Private); 15.7% (Public Hospitals) with 91% of households using the nearest facility of its kind; the outstanding 8.3% cited other reasons in not using the facilities. Of this percentage, 33.8% gave reasons such as excessive waiting times, 15.9% non-availability of medicines and 10.7% rude/uncaring staff, (Lehohla, 2006:4). Satisfaction levels for private healthcare facilities were higher (92.4% of users were satisfied with the services received), while public health care reflected only (54.3%) (Day & Gray, 2010:311).

A common perception since 1994, is that primary healthcare services are grosslyinadequate, a result of an assessment of hospital-based services for four chronic diseases (diabetes, hypertension, asthma and epilepsy) conducted by Steyn and Levitt in eight Gauteng hospitals. The report shows that the causes of service inadequacies in these hospitals included shortage of staff, lack of training, short consultation times, little patient education in self-care and infrequent use of management guidelines and standard assessments (Steyn & Levitt, 2005:228).

Arries and Newman (2008:1) reason that the healthcare in South Africa needs a coherent, transparent, efficient, effective, accountable and responsive vision transformation. This transformation process of people-centred and result-driven service characterized by equity, quality, timeous delivery, and a strong code of ethics rests social change awareness, emphasis on the community’s need for self-expression as well as environmental, economic and political issues affecting it.

The following narrative gives an insight into the nature of services received in publichealthcare facilities:

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“A pregnant woman in a complicated stage of labour was referred to a regional hospital for child delivery and an ambulance service was called in for the transfer from a district hospital. When the ambulance team arrived, the nurses were on a teatime break, as such not mindful of the patient’s critical condition. The ambulance team waited for an additional 45 minutes while the pregnant woman was in excruciating labour pain.” Quality of service is a measure of responsiveness, courtesy, customer orientation, reliability, confidentiality and care, (Arries & Newman, 2008:2; Fitzsimmons & Fitzsimmons, 2011:4) that show either positive or negative service perception of a health provider by a patient (Arries & Newman, 2008:2). Elaborating on the lack of service commitment and service orientation, The SA Health Act and The SA Constitution provides legal rights and obligations to practice responsibly, in accordance with the nurses pledge of service ‘To serve the community with respect and dignity’, which often remains unfulfilled. (Arries & Newman, 2008:2).

To match these demands, Arries and Newman (2008:2) point out the need to avoiderror in every single procedure especially in filling proper prescriptions, administering medication, tidying waiting areas, timeliness (promptness in service), answering questions (responsiveness), and politeness (even if the patient is overbearing, inconsiderate and downright offensive). Reassuring patients (courtesy) and friendliness are to be the top most priorities, Arries and Newman (2008:2) concluded.

2.8 Hospitals Efficiency in Gauteng

There is the urgency to assess efficiency and productivity of hospitals given the theorised deep magnitude of inefficiency, in addition to macro-economic and socio-demographic realities of this province. However, the dearth of information on hospital efficiency in the Gauteng province shows limited priority given to it in the provincial health system. Kirigia et al. (2008:4) investigated the technical efficiency of 155 PHC in Kwa-zulu Natal, Eastern Cape, Northern Cape and Western Cape, and Maseye et al. (2006:479) conducted the technical efficiency study of 86 public hospitals. The results of the analysis found that public hospitals are technically inefficient. According to Kirigia et al. (2008:2), monitoring the limited resources such as human resources, pharmaceutical supplies, non-pharmaceutical, clinical technologies and ambulances helps to improve the quality of health, reduce waste and implement policies geared to productivity enhancement which facilitates the attraction of more domestic and external resources into the health sector. The researchers remarked that population needs are unlimited and insatiable, striving to meet these demands makes efficiency an inevitable process (Kirigia et al., 2008:2). Zere (2000:11) and Taylor (2009: 1) reveal that in practice health administrators give little attention to efficiency, instead focusing on health sector reforms and mobilising

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additional resources for healthcare through user fees and other finance modalities, this results in inflated costs of service. These researchers warn that inflating the cost of service deteriorates to inefficacy and inequity that denies citizens the opportunities to realise health improvements at zero cost and this culminates to inefficiency, making it immoral and unethical. According to Zere (2000:12) and Kirigia et al. (2008:2), inefficiency emanates from over-staffing, stock wastage, excessive hospital length of stay, excessive waiting period, and over-prescribing.

Efficiency, as a very important factor in health systems takes cognisance of the different stakeholders and their needs, wants and expectations resulting in improved profitability outcomes.

2.9 Gauteng Public and Private Healthcare Service Overlaps

Satisfaction of patients’ values and needs leads to customer loyalty and constant patronage. This fact contrarily affected the public healthcare facilities. Berger, Thomas, Vital and Wang (2011:2) and Hassim, Haywood and Berger (2008:164) predict that private healthcare sector largely run on commercial lines has begun to take over many tertiary and specialist services, caused by long appointment schedules to patients by the public hospitals due poor performance of service.

Identifying serious service overlaps existing between the private and public healthcare sectors, Hassim et al. (2008:164) maintain that the inequalities that exist in accessing healthcare services is made evident by the excellent services offered in the private sector. The researchers warn that non-prioritization of this problem through regulation to end the inequitable and unaffordable distribution of health services, will perpetuate the suffering of the communities. The tax subventions and benefits offered to private medical scheme high-income earners are such that the more expensive the product is, the greater the government subsidy allocated to it. High-income earners and the middle class prefer to use these benefits in private hospitals believed to offer a better service, Hassim et al. (2008:164).

Berger et al. (2011:2) attest that government inability to meet the demand of patients(80%of the population) in areas of the PHC is a concern especially in anti-retroviral drug rollouts and immunization vaccines. The inability to match demand to service forces the Gauteng government to contract private healthcare sectors often both in the utilization of its health facilities and professionals for specialised services. For instance, private hospitals in Johannesburg offer medical services to the Department of Correctional Services prison inmates, aggravated by the private sector employing health professionals and medical expertise originally trained at the state expense.

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2.10 Conclusion

The burden of diseases, limited available resources, changing policies, incoherentinformation dispersion, managerial incapacity and constant restructuring of leadership have led to disruptive uncertainties and a lack of focus in healthcare service delivery (Gauteng Department of Health & Social Development, 2011:46). In most cases, neither the political leader nor the head of department is a health professional, resulting in no decision or an inappropriate decision made regarding health related issues, particularly in health service delivery.

The high mortality and morbidity rate, HIV and TB infection resurgence rates, and theincreased population density constitutes major problems in service delivery. There is a lack of culture of using information for management purposes. Though the policies are established, WHO and MDG benchmarks set, there is an unclear understanding of the resources, skills and capacity requirements for the implementation or the resource gaps and constraints experienced at the service level. There is a need to revalidate the concepts and theories that underpins the allocation and utilization of resources, service delivery, and satisfaction, models of care, capacity planning and leadership.

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Chapter 3: Conceptual Theories and Performance Models


3.1 Introduction

In response to people’s expectations and fair financial contribution and to maintain the healthy status of the population, there is a need to examine the strategies, theories, concepts and models of the healthcare systems that could alter the service performance.

3.2 Healthcare System and Governance Concept Current health challenges and the deteriorating health inequalities within the province make governance an utmost priority that ensures proper allocation of resources, accountability and performance monitoring.

According to Balfour (2007:4), health is not only the absence of disease and infirmity, but also a complete state of physical, mental and social well-being that involves promotion, prevention, diagnosis, treatment, and rehabilitation, which must be co-ordinated in such a way as to achieve a good outcome (Balfour, 2007:4; Omachonu & Einsprunch, 2010:10). However, the WHO (2010:50) defines a health system as “an ensemble of all public and private organisations, institutions and resources and other activities to improve, maintain or restore health. Health systems include both personal and population services as well as activities that influence the policies and actions of other sectors to address the social, environmental and economic determinants of health.”

Marks et al., (2011:19) argue that public health systems do not only include resources, organisations and services but also are constrained by the boundaries of the societal activities beyond health operatives. Prominent among the functions of the health system include stewardship (governance), training and financing. Governance as shown in figure 3.1 aligns the different efforts to optimise health gains. The performance of these functions minimizes the gaps between customer’s expectations and the service delivery (Fitzsimmons & Fitzsimmons, 2011:117).

The taxes and social insurance revenues collected by the government support the key roles demanded by the public from government in providing good health systems. Government itself regulates and enforces the operation of health services aimed at improving health system performance.

Government through its financing mechanism such as budget allocation, rising of health awareness, taxation, and adoption of specific health standards and regulationof pharmaceuticals is at the centre stage of meeting the patient’s healthcare service

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expectations (Department of Health, 2005:3).

Figure 3.3: Concept of Health System and Public Health Boundaries

Source: Marks et al., 2011:19.

The various consultative councils and monitoring committees (shown in figure 3.2) from all hospital levels to the hospital management and the community are entrusted with the resources, responsibilities and protection of the public interest (Ogunefun, Moyo, Mbatha, Madale & English, 2012:1).

Figure 3.4: Health Monitoring Committees

Source: Gauteng Department of Health, 2003:5.

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The monitoring committees through the active participation of the politicians, managers and medical experts play a stewardship role in ensuring good health as a human right by acting as an intervention ladder between the government and its policies, regulators of health norms and standards, monitoring of the system and bridging the service gap.

The health sector involves a complete transformation of national healthcare, the delivering system, all relevant institutions coupled in addition to thorough review of legislation, organizations and institutions related to health. It ensures community participation in every service decision-making process, the need for teamwork and affirms that all health practices are in line with international norms and the WHO recommendations (Department of Health, 2005:1). Community participation is intermediary or the bridging gap between the health governance policy, legislation development levels, implementation and practice levels, fully involved at the national and provincial committees (the national and provincial health councils and the consultative forums) as well as the district and hospital boards (Department of Health, 2003:5).

3.3 Hospital Levels and Service Structure

Hospitals in South Africa consist of three levels (figure 3.3), each level implies different levels of service created primarily for in-patient care (WHO, 2006:8-6), although outpatient and emergency care does exist (Cullinan, 2006:10).

3.3.1 Primary Healthcare (PHC)

PHC is the first point of service contact in a healthcare system, defined by the Bailiere Nurses dictionary (2005:318) as “the care given to the individuals in the community at the first point of contact with the primary healthcare team.”

According to (Cullinan, 2006:12), a hierarchy of health services is established from the primary level as the first point of call via local clinics and community health centres at explicitly free service which operates 8 hours a day. This is done to effect efficient use of scarce resources, with the unsuccessfully treated or more complex health problems being referred to hospitals. The primary service level, usually run by nurses is for preventive, promotional, curative and rehabilitation services, with a particular emphasis on family planning; provision of essential drugs; treatment of sexually transmitted infections; promotion of food supply and nutrition; care for those with chronic illnesses; immunizations; mother and childcare and trauma. Major challenges facing clinics include retention of qualified professional nurses, massive patient load, irregular or no visits by doctors and the pressure exerted by HIV antiretroviral treatment and CD-4testing (Cullinan, 2006:12).

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Figure 3.5: South African Healthcare Delivery System

Source: WHO, 2006:8-6.

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3.3.2 Hospital

Hospital basic definition is paramount in order to access performance efficiency of healthcare facilities. Cullinan (2006:8) describes hospital as “an organized effort to provide a specific set of medicinal services, usually physically located in one or several buildings and related to specialized cure (diagnosis and treatment) and care (as opposed to the primary care level) with the input of health professionals, technologies and facilities”.

Ngwenya (2007:164) categorises hospital into two broad components namely private and public healthcare.

Private HospitalAccording to Ngwenya (2007:164), private hospital is all private health providers operated by health professionals in private state-of-the-art facilities whose main funding mechanisms are medical schemes, life and short term insurance, non- governmental Organisations and out of pocket payments. It is a service-for-profit institution renowned by its anti-competitive pricing of medicine, and laboratory services with a relatively good provision of specialist services. This sector is presumed to be a deterrent cause of high medical scheme premiums. With a never compromised quality of service and having, 37.3% of medical scheme members’ in South Africa resident in Gauteng (Ngwenya, 2007:164), there is a differentiating service delivery factor between the two categories in this province.

Key private health service organisations include the Hospital Association of South Africa (HASA), which comprises over 183 private groups and independent hospitals and clinics. The Board of Healthcare Funders (BHF) represents 95% of all medical schemes and sets tariffs for healthcare services as a guideline to its members and the National Association for Pharmaceutical Manufacturers (NAPM) (Ngwenya, 2007:172).

Public HospitalNgwenya (2007:164) describes it as health institutions owned by government, operated in government facilities and managed by health professionals employed by healthcare institutions to care for the community. It is predominantly a non-fee-for-service and relatively low fee-for-payment services covering a wide scope of care, rational healthcare policies and community based staff. Various factors such as nature and degree of sickness, proximity to patients, and availability of services determine the governance of the structure level and its operation.

The most common levels available in South Africa as listed by Ngwenya (2006:13)include:

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District hospitals (Level 1), the first referral hospital level with access to basic and diagnostic services, therapeutic services, basic laboratory testing, operating theatres but no intensive care units. Staff comprise of ordinary general practitioners. It constitutes 64% of the total 388 public hospitals. According to Department of Health (2002:3), in addition to integration of clinics’ responsibilities, level one hospitals scope lays is in obstetrics, geriatrics, pediatrics, surgery, psychiatry and basic family and primary health care, functioning 24 hours per day, referring patients to regional hospitals as appropriate. A release on a set of norms and standards called ‘The District Hospital Service Package for South Africa’ by the Department of Health (2002:3) spells out the distinct role of district hospitals in supporting PHC, and as a gateway to more specialist care (Cullinan, 2006:13).

Classified into two specialized units, a regional hospital (Level 2) is a single specialist and general service. Notably, Gauteng has more level two hospitals than level 1 (Cullinan, 2006:13). Both General and specialized level 2 hospitals take referrals from a level 1 hospital and general medical practitioners serving in the communities. According to Cullinan (2006:16), general (regional) hospitals (level 2) have at least five permanently staffed specialists out of the eight core specialties of surgery, medicine, radiology, pediatrics, obstetrics, gynecology, diagnostics, orthopedics and anesthetics. The researcher points out that unlike district (level one) hospitals, no norms and standards, even draft ones, have been developed for this system, yet it is the most overburdened among all health institutions in South Africa further effected by the various complicated health problems that culminates service inefficiency (Culinan, 2006:17).

National Referrals (Level 3) refer to national, central and national referrals (tertiary) hospitals (level 3). Cullinan (2006:16) further classifies the different categories as follows: provincial tertiary hospitals (tertiary 1) and national referral hospitals (Tertiary 2). This facility constitutes less than 4% of the public sector hospitals providing specialties such as cardiology related queries, endocrinology, geriatrics, nuclear medicine; pediatrics sub-specialties, renal

plants, hematology and spinal injury care services.

Specialized hospitals have a wide range of possible specialist services for longer chronic in-patient care, constituting 16% of the entire public health sector and providing extended specialist care for spinal injuries, maternity, heart, infectious diseases and psychiatric care (Cullinan, 2006:16).

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3.4 Healthcare Technology Innovation Concept

This concept is an inevitable accelerant intentionally introduced, applied within a role,characterised in the form of product, process, service and structure, either disruptive or non-disruptive (Omachonu & Einspruch, 2010:4), in the form of new services, technologies and ways of working, regulated by law and utilized by the system stakeholders in ensuring good health outcomes (Adams et al., 2008: 14). This concept is designed to perform major healthcare functions that significantly benefit all, and assists patients in adopting heathier life pattern (Omachonu & Einspruch, 2010:10).

Inappropriate use of these innovations, the researchers warn, may result in death, disability or permanent discomfort (Omachonu & Einspruch, 2010:9). For instance, a mistake in injection of spiral anaesthetic during child delivery may cause paralysis of the patient that may lead to litigation. Hence, there is a need to match the stakeholders’ expectations for effective and efficient performance.

Non-disruptive sustains and improves an existing idea to solve an inherent problem, meet stakeholders’ needs, wants and expectations (table 3.1) and accomplishes the expansion of new opportunities. For instance, a new type of thermometer called the ‘Digital Genius Thermometer’ takes fractions of a second to read unlike the analogue version. In addition, the use of the Dina map, for blood pressure monitoring has replaced the old sphygmomanometer.

Disruptive (radical) is either revolutionary, transformational, non-linear that disorders the old systems and creates new markets, or values while marginalizing old ones and delivering new values. For instance, the use of telemedicine by doctors to prescribe drugs or to examine X-rays remotely.

Table 3.6: Stakeholders Needs, Wants and expectations

Source: Omachonu and Einspruch, 2010:9.

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Innovation is inevitable in healthcare (Adams et al., 2008: 14) and these include product, process, service and structural innovation (society and management related policies) (figure 3.4).

Figure 3.6: Types of Healthcare Innovation

Source: Adams et al., 2008:14.

Omachonu and Einspruch (2010:4) explains the product innovation as what the customer pays for, while the process innovation typically is the delivery method where the customer does not pay directly but the process delivers the product or service, which allows for a significant increase in the value delivered. Structural innovation usually affects the internal and external infrastructure (facilities) and creates new business models, for instance, policy and societal innovation, collaboration, service and business model innovations. Omachonu and Einspruch (2010:4) further emphasise that innovation not only concerns technology breakthroughs in medical devices, procedures and treatment, but information networking that includes security and privacy of patients with information technology revolutionising things in major ways, mainly with offshore services and drug safety monitoring on a global scale.

Omachonu and Einspruch (2010:6) add that outsourcing of diagnostic services (Imaging–X rays, Monograms and Specialist consultations) provides care to patients in hard -to-reach and under-serviced locations (telemedicine). Drug safety monitoring

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on a global scale (Med Watch) involves investigating and reporting on adverse drug reactions using international databases on drug safety, making use of available high quality information both for patients and doctors by drawing materials from on-line textbooks and medical journals, (Omachonu & Einspruch, 2010:6).

3.4.1 Integration of Health Information Systems

Integrated information exchange (figure 3.5) aligns all health systems and incentives (medical, governance and training) in order to achieve and exceed service expectations; transforming care delivery through engagement of patients to ensure safe, easy utilisation, confidentiality and efficient healthcare for the public (Weeks, 2012).

Figure 3.7: Health Information Exchange

Source: Weeks (GSTM Lecture notes, 2012)

A resource intensive information system not necessarily of high-tech is vital both to service providers on how to achieve the best practice and the individuals on how to manage their own health (WHO, 2006b: 22).

Most health information function as solo (own rules and formats) and which inhibit the information from being readily available or globally integrated. Different practitioners cannot read a patient’s chart in one health institution due to a conflict between encryption and other software, making it impossible for systems to exchange data electronically when methods, measures and languages are different (Omachonu & Einspruch, 2010:6).

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Essential knowledge (figure 3.6) ensures what alternative best fits the patient. A lack of relevant clinical knowledge and patient information forces most health professionals to rely exclusively on their own experience based on the trial-and-error method, better known as the expert-or-experience based method. Notably, due to enhanced technologies, personalized and evidence based medicine increases the probability of safe and effective health delivery (Adams et al., 2008:4).

Actualising the personalized information age has needed the patient to understand the shift in the trend of making improved decisions and value care and health care plan options. This co-produce stage helps patients to optimize their choice of benefits, creating the next stage in helping patients to bridge the gap between their health needs and the ability to underwrite these services through holistic healthcare and financial and retirement plans (Adams et al., 2008:4).

Figure 3.8 How increasing value increases information intensity

Source: Adam et al., 2008:6.

3.4.2 Healthcare Innovation Conceptual Framework

According to Omachonu and Einspruch, (2010:10), every health facility performs fivemajor functions including prevention, diagnosis, treatment, education, research, and outreach, for which the cumulative objective (figure 3.7) is to achieve a higher order of quality, efficiency, costs, safety and reasonable outcomes. To make this possible, these researchers emphasize that health providers rely on information and innovations in technology for success, which lies in patient satisfaction. However, not meeting the needs raises concerns for the patient’s welfare. The processes to achieve this, require a redefinition of the relationship between the health providers and the patients (Omachonu and Einspruch, 2010:10).

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Figure 3.9: Healthcare Innovation Framework

Source: Omachonu and Einspruch, 2010:10.

Adams et al. (2008:23) using figure 3.8 affirms that these processes involve transforming value, care delivery and consumer responsibility. The researchers epitomised that assisting patients to lead heathier lifestyles, and self management in a co-ordinated care across venues and time, may only be achieved through shared decisions provided by developed robust information infrastructures. Informed patient preferences can be achieved by both the patients and health provider focusing on prediction, early detection, treatment and care.

Figure 3.10: A Win-Win Innovative Transformation


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3.5 Performance Assessment Framework

Acceptable health outcomes demand the evaluation of hospitals in terms of achievement of the goals of patients, the medical personnel, the management team and society for the satisfaction of all. Shaw (2003:4) and WHO (2003:8) concur in defining performance (effectiveness) as “the achievement of desired goals (Clinical and Administrative) based on competencies in application of present knowledge, available technologies and resources, efficiency in the use of resources with minimal risk to the patient; satisfaction of the patients, and outstanding health outcomes”.

Wilson (2012:7) describes performance as measuring the effects of medical practices and techniques on individuals’ health and well-being that culminates in a relationship between the level of resources invested and the level of results or health improvement. The hospital performance addresse’ not only the responsiveness to community needs, commitment to health promotion and service integration in the overall delivery system but also provides services to all patients, notwithstanding, physical, cultural, social, demographic and economic barriers.

3.5.1 Outcome Based Performance Assessment Framework

Shaw (2003:4) affirms that assessing performance is a means of defining hospital activities and comparing that with the original targets (Standard) in order to identify opportunity for improvement. The influence of technology, service delivery and finance on such building blocks (figure 3.9) as health workforce, leadership, skill mix, training, information and work environment propel performance for proper achievement of notable health system targets in meeting the relevant outcome.

Shaw (2003:4) in his ‘Health Evidence Network’ highlights that the principal methods of measuring hospital performance must be regulatory inspection, public satisfaction surveys, third party assessment and statistical indicators. Shaw’s survey theorises that the effectiveness of measurement of the strategies depends on many variables such as their purpose, national culture and organizational style, application and the results usage (Shaw, 2003:4).

The Survey addresses what is valued by patients (experience and satisfaction) andpublic, comparing it against explicit standards and third party assessment which takes into account standards (compliance with international standards), peer review (self-regulation) and by accreditation programmes (what may be improved rather than failures). Observations and experimental data based on statistical indicators act as a guide to standardize management, encourage improvement, and empower patient choice and to demonstrate a commitment to transparency (Shaw, 2003:4).

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Figure 3.11: Performance Framework Showing the Health Outcomes

Source: Soumya et al., 2009:8.

3.5.2 Performance Assessment Tool for quality improvement in Hospitals Model (PATH)

PATH is the most commonly recommended and accepted health performance model that incorporates the essential qualities of all healthcare models. PATH is a data collection tool on performance for hospitals used to compare hospitals with their peer groups (Veillard, Champagne, Klazinga, Kazandjian, Azah, Guisset, 2005: 3; World Health Organisation, 2007: 6). It encompasses six dimensions (figure 3.10 and table 3.2), four domains and two transversals. The four domains consist of clinical effectiveness, efficiency, staff orientation and responsive governance, while safety and patient-centeredness make up the transversal perspectives (Veillard, et al., 2005:3; WHO, 2007:6).

Responsive governance explains the extent the hospital relates to the community needs; continuity of health services and care irrespective of social, physical, demographic and cultural inclinations.

Patient centeredness evaluates the services provided for the needs and expectations of patients; prompt attention, access to supplier networks, communication processes and respect for patients in terms of privacy and confidentiality, dignity and autonomy.

Clinical effectiveness refers to appropriateness of care and conformity with healthcare processes by making use of the existing knowledge to achieve good health outcomes.

Efficiency is the minimal use of resources such as technologies and productivity to achieve maximum output (best possible care).

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Figure 3.12: PATH Conceptual Model

Source: Veillard. et al., 2005:489; WHO, 2007:6.

Safety is the evidence of risk reduction demonstrated by the use of structures in the hospitals, comprised not only the environmental safety but also those of staff and patients.

Staff orientation involves the extent to which the staff are suitable for the job; working in a supportive environment, identification of individual needs, health promotions, safety initiatives and health status (Veillard et al., 2005:489; WHO,

2007:6).

Table 3.7: Key Hospital Performance Dimensions

Source: WHO, 2007:6.

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http://intqhc.oxfordjournals.org/content/17/6/487/F2.large.jpg


These key dimensions on performance of the organisations capture the most important aspects of health. The impact of the operational design of the healthcare delivery system occupies the primary consideration when evaluating the relationship between health care organizations and patient; the nature of support, resources and expectations governs the Clinicians and the hospitals while the nature of the relationship is based on communication and patient advocacy (figure 3.11). These triad entities have a unique but interrelated perspective on the needs associated with

health care performance (Cowing, Davino-Ramaya, Ramaya, & Szmerekovsky, 2009:75).

The hospital needs include the operational efficiency, operational effectiveness (clinical performance measures and risk management) utilised by the clinicians to deliver quality care in an adequate organisational support which aid in meeting the patients’ psychosocial needs and perception of service in order to achieve personalised care and enduring health outcomes.

Figure 3.13: Performance and Quality Measures (Triad Interactions)

Source: Cowing et al., 2009:75.

There is a belief that patients who perceive an encounter with a patient-centred clinician will show better recovery and better emotional health and fewer diagnostic tests needs. In addition, patients who comply more with the treatment planned are satisfied in a well-developed clinician-patient interaction. Furthermore, they are likely to understand their role in the recovery process, as they adhere with the recommended treatment, resulting in improved health outcomes (Cowing et al., 2009:75).

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These performance outcome measures (figure 3.12) include technical and objective guidelines and standards. The functional process (service delivery) is typically a function of subjective assessments that results in the health outcomes and performance measures (Cowing et al., 2009:76).

Figure 3.14: Determinants of Performance

Source: Cowing et al., 2009:75.

The public considers hospital performance based on the principles of equity, effectiveness, efficiency, quality of services and consumer satisfaction. Good management demands validity, reliability and accuracy of the hospital performance, compared to the standard norms.

These discussions prompt a contentious question ‘how does the performance of hospitals compare standards of healthcare activities and its attributes with their results (value) in service delivery?’

3.6 Healthcare Service Delivery Concept

Service delivery is a dynamic concept that changes as the needs of the stakeholders’ changes but its characteristic nature of matching service with demand to create satisfaction, accomplished through systematic input-process-outcomes perspective remains the same (WHO, 2006:8-2).

Grönroos according to Fitzsimmons and Fitzsimmons (2011:4) explains service as “activity or series of activities of more or less intangible nature that normally, but notnecessarily, take place in interaction between customer and service employees and /or physical resources or goods and/or systems of the service provider, which are provided as solutions to customer”

In a slightly different vein, the WHO (2006:9) describes healthcare service delivery as“the way inputs are combined to allow the delivery of a series of interventions or

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health actions. As the main function of the health system, it also performs the immediate output of the inputs of the other building blocks such as health workforce, medical products and finances.”

The deterministic nature of the inputs facilitates and manages the process to obtain the outputs that creates an observable impact (figure 3.13). The inputs influencing factors such as the rising cost, inaccessibility to timely care, globalization, consumerism, changing demographics, proliferation of new treatments and technologies, legislation and policy and changing lifestyles control healthcare change (Adams et al., 2008:5; Motsoaladi, 2011:11).

Most countries have similar healthcare satisfaction problems but differ in the modelsfor financing and delivering healthcare, especially in areas with growing resource challenges, new approaches to promoting health, delivery care and a focus on value from the entire health system.

Figure 3.15: Systematic View of Service Delivery

Source: WHO, 2006:8-2.

The high value attached by healthcare givers to diagnosis and treatment when the patient is ill makes delivery costs highly unaffordable and unattainable in the restoration of full pre-disease health for chronic illnesses, however, proactive care strategies, focusing on personalized prevention, production, early detection, treatment and disease management creates a healthier population and at a lower cost. Different dimensions of value (figure 3.14) exist in health care with the components of health system values balanced with each other. The disparity existing in equity and ability to activate healthier lives for citizens, to continuously improve, innovate and access healthcare is so evident that the healthier population status demands stringent measures. For instance, a potential diabetic, using a preventive approach requires a diabetic management strategy, while a complicated diabetic may require dialysis, amputation or even a kidney transplant.

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Figure 3.16: Changing Value Dimensions


Undoubtedly, the health financial burden is heavy on government with a shift toindividuals (citizens) to manage the rising cost of their healthcare and making decisions of better life style choices (figure 3.15), such as proper diet, adequate exercises in addition to smoking abstinence.

Figure3.17: Citizens Health Decision Approach


High value care demands the participation of patients in the health decision-makingprocess and in extreme cases, the value selection is left for the professional to provide cost evidence of benefits and risks of viable alternatives.

Actualising the personalized information age needs for the patient to understand the shift in the trend of making improved decisions, value care and health care plan options. This co-produce stage helps the patient to optimize the choice of benefits,

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which creates the next stage of supporting the patient to bridge the gap between health needs and the ability to underwrite these services through holistic healthcare, financial and retirement plans.

3.6.1 Service Delivery Models

Hospitals fit into one or more of the several existing service delivery models (tables 3.3 and 3.4). Adams et al. (2008:17) conceptualised the evolution of service delivery models as community health network, centre of excellence, medical concierge and price leader, with particular focus on such value dimensions as access to healthcare, clinic quality, service quality and cost.

Table 3.8: Evolution of Service Delivery Models


Community health networks ensure access optimization across a definedgeographic area while centre of excellence optimizes clinical quality and specificmedical conditions. Medical concierge (special service) focuses on optimization ofthe patient experience in an information Technology (IT) enabled administrative relationship, while price leaders (mostly for the private sector) option ensures the optimization of productivity and workflow.

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These service delivery models are characterised by the following attributes in improving their competencies:

Empower: ensure that citizens are better informed to assume accountability. Enable through IT: assist in creating a high value care, effective management,

governance and electric network to improve access to and sharing of information between patient’s and clinician’s health and lifestyle choices.

Innovate: provides a dedicated funding and leadership to differentiate the care services.

Optimize: operational efficiencies focuses directed to optimizing both administrative and clinical processes.

Collaborate and integrate: delivering health for both traditional and non-traditional care values will promote care interventions, care coordination and accounting of quality.

These models seem inadequate but can be improved, redirected and possibly expanded to match a service delivery process. The Models of health service are intermingled with regulations, patient engagement, organisational capacity, information access and leadership. The effectiveness and efficiencies of these models lay within the operation of the six performance interventions domains shown in figure 3.16 below.

These domains determine the six basic PATH dimensions of effectiveness, efficiency, accessibility, patient-centred, equity and safety healthcare. Consistent and strong leadership at all levels forms the basic core of the health system in achieving best health outcomes. A resource intensive information system, not necessarily of high-tech is vital both to service providers to achieve the best practice, and individuals to manage own health (WHO, 2006b: 22).Figure 3.18: Six Domains of Performance Interventions

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Table 3.9: Service Delivery Models with Improved Competencies

41


Source: The WHO, 2006b: 21.

3.7 Healthcare Efficiency Concept

Efficiency (figure 3.18) is a relative term challenging to define and differently viewed depending on the element of healthcare valued but with a commonality centred on services (inputs) and outcomes. According to Academy Health (2006:6), the Medical Payment Advisory commission (Med PAC) defines it as “the Use of fewer inputs (avoidance of waste) to get same or better outcomes which sufficiently meet patients healthcare needs and satisfaction”.

To make explicit the content and use of healthcare measures, three levels of efficiency topology exist (Figure 3.18); the perspectives (who is evaluating the efficiency of what entity and objective), outputs (what type of product is being evaluated) and inputs (what resources are used to produce the output) (McGlynn, 2008:1). Healthcare efficiency consists of technical, productive and social efficiency, functions of how well the resources are utilised to obtain health improvements (Kirigia et al., 2008:2; Peacock, Cohan, Mangolini & Johansen, 2001:7).

Kirigia et al. (2008:2) question the various types of efficiency as contradicting to the values of the health practitioners especially ‘what and how many healthcare services inputs will yield the greatest efficiency and with what risks and benefits?’ Health outputs conceptually and empirically are complicated because of many variables of which some are exogenous to the healthcare sector, for instance, education, household decisions and income.

Farrell, Debreu and Koopmans (In Zere, 2000:17) proposed the measurement of efficiency relative to a best performance frontiers determined by peer group representatives on the same frontier, referred to as technically efficient (the one operating on the best practice production frontier). Kirigia et al. (2008:3) explain technical efficiency as “the use of maximum health services out of available

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resources or minimising the use of available resources to produce a given level of health services, viewed as economic efficiency (a product of technical and productive efficiency)”.

Figure 3.19: Topology and Types of Efficiency

Source: Kirigia et al., 2008:2.

Output-oriented and input-oriented are the two approaches used to measure hospitals technical efficiency. The output-oriented approach measures how much additional output hospitals could produce while still employing its current inputs, interpreted as a hospital’s productivity relative to best practice, showing flexibility in altering the level of output especially if the hospital has greater capacity to raise revenue, in the case of private hospitals.

The input-oriented approach measures how many fewer resources a hospital could employ and still produce the same level of output, interpreting efficiency as the hospital’s resource intensity relative to best practice. This approach is appropriate for public hospitals, which operate under a capped budget with less flexibility to change their output, but can alter the use of inputs. Reducing the input proportionally in the current input-output mix while keeping the output proportion constant to increase efficiency, generates the input-oriented.

Technically efficient hospitals uses less weighted inputs per weighted output or more

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weighted output produced per weighted input than the hospitals on the ‘best practice frontier’.

TE Score = weighted sum of output÷weighted sum of inputs.

Technically inefficient hospitals use more weighted inputs per weighted outputs, meaning that it produces less weighted output per weighted input than those hospital(s) on the best practice frontier. When the hospital is operating at optimal scale, constant return to scale (CRS) exists, contrarily; technical efficiency decomposes to pure technical efficiency referred to as Variable Return to Scale (VRS).

Assuming (CRS), the efficiency of hospital jo can be obtained (kirigia et al., 2008:3)

Maxhg = ∑r=1

s

UrYr j0 Subject to ∑i=1

m

ViXij0

∑r=1

s

UrYrj−∑i=1

m

ViXij≤0where j=1 ,………N

; ∪rVi≥0where

Yrj (r=1 ,… .. , s)=¿ Observed amount of output r from hospital j

Xij (i=1 ,…. ,m )=¿Observed level of input 1 used by hospital j

Ur = Weight given to output rVi = Weight given to Input i

Assuming VRS, efficiency becomes

Maxho =∑r=1

s

UrYrjo+Uo

Subject to ∑❑ViXi j o=1

∑UrYrj −¿ ∑ViXij+Uo≤0 j=1 ,…. ,n

Ur, Vi ≥ 0 , Uo ≥ 0

Osman (2010:11) and Maseye et al. (2006:476) treated the weights Ur and Vi as unknowns and used linear programming to obtain these weights, emphasising that measurements of inputs and outputs are in their natural units, making the weighting system necessary unimportant. 3.7.1 Related Efficiency Terms

Returns to Scale (RS)According to Kirigia et al. (2008:4), this is the response of output (e.g. hospital admission) to changes in the size/scale of a hospital in the end. These changes are:

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Constant return to Scale (CRS): when output increases exactly in the same proportion as the input; doubling output leads to doubling of input; TE= Scale

of inefficiency. IRS (economic of scale) is when the output increases by a larger proportion

than the input, attributed to indivisibility of health inputs: greater specialisation, innovation and increased performance of human resources for health (due to motivation and rewards incentives) (Kirigia et al., 2008:4).

Decreasing return to scale (DRS) occurs when doubling the input does not give a corresponding double amount of output, due to shortage of complimentary inputs (medicine), low levels of staff motivation and leadership problems (co-ordination and supervision). Variable Return to Scale (VRS) constitutes the IRS and DRS.

Congestion inefficiency results due to excessive use of resources and congested technology.

Production function (PF) exists as a relationship between the input quantities and the resulting output quantities.

Several steps used in measuring empirical estimates of efficiency include the estimation of the frontier and the calculation of the individual hospital deviation from the frontier. In estimating the frontier, a non-parametric approach involving linear programming called Data Envelopment Analysis (DEA) is applied.

3.7.2 Application of Data Envelopment Analysis (DEA)

Charness et al. (1978) first proposed DEA (a non- Parametric method) for measuring decision-making units (DMUs) for such complex institutions as hospitals using linear programming methods to establish data frontier from the sample, provided all the DMUs lie on or below the frontier. The DEA tool applies as the measure of efficiency when random noise (epidemic, weather and strike) is less of a problem, multiple input-output products are relevant and price data is difficult to find.

Maseye et al. (2006:476) in their findings state that DEA estimates technical, scale efficiency that handles multiple inputs as well as multiple outputs that accommodate inputs and outputs of different measuring units, and does not require any assumption of a functional form in relating inputs to outputs. DEA compares decision-making units directly against a peer or combination of peers.

According to Hollingsworth et al. (1999) (In Rattanachotphanit, 2007:7), the use of DEA method of analysis is on the increase in application in order to measure the technical performance of healthcare services due to its ability to accommodate the multiple input-output natures of healthcare provisions. The researcher argues that

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60% of healthcare studies use DEA alone and 20% use DEA-Regression Mix while the rest of the 20% uses other methods. The determining factors of efficiency using DEA Analytic method shown in figure 3.18 include the inputs and outputs; and service delivery process of performance satisfaction.

The DEA accuracy to estimate performance measures, however, depends on inclusion of relevant inputs and outputs, and the use of accurate data, in addition to appropriate and well-defined models that may change value dimensions.

Figure 3.20: Determination of Hospital Efficiency Using DEA Analysis

Source: Own Research

The efficiency of each hospital in producing the three outputs was estimated by dividing each of their outputs with the respective input to obtain the hospital(s) with the highest ratios. The higher the ratio of an output to input the more efficient a hospital produces an output maximally.

Table 3.5 gives a hypothetical illustration of three hospitals with one input and two outputs showing Gamma hospital as the highest with 125 and 163 for the OP visits and admissions respectively for each member of the technical staff employed. To derive the production possibilities frontier, a graph (figure 3.19) of E on the y-axis against D on the x- axis for the three hospitals is plotted using the same input on both axes. The efficiency frontier, which is the fundamental concept of DEA, is derived by drawing straight lines from Gamma hospital to the x-axis (labelled OP visits/staff) and from Gamma to the y-axis, (labelled Admission/ /staff).

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Table 3.10: Hypothetical illustration of DEA Analysis

Source: Own

The efficiency frontier line drawn from Gamma hospital as the most efficient hospital(s) is the measure of threshold against the performance of the other two hospitals in the dataset/sample, representing a standard of the best technical performance achieved from available input and technology endowment.

Figure 3.21: Hypothetical Illustration of Technical Efficiency


Consequently, this production frontier shows the relative efficiency performance of these hospitals and ‘envelops’ the inefficient hospitals within it, with the most efficient considered to be 100 per cent technically efficient and others with relatively less than 100 per cent.

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Assuming constant returns to scale (CRS), the technical efficiency in an input-orientated scenario (reducing its input, with its outputs held constant) is calculated by the ratio of its distance from the origin over the distance from the origin to the point of intersection on the efficiency frontier, respectively, Alpha, Omega and Gamma hospitals being 70.4%, 96.8% and 100% respectively. Due to non-linearity of hospital services, it is necessary to assume variable return to scale. Consequently, the technical efficiency becomes Alpha (61.6%) and Omega (81%). These health facilities could be efficient, if there was an increase in output in the same proportion, keeping the input constant. This implies that Alpha and Omega facilities require 38.4% and 19% respectively becoming technically efficient. The scale efficiency (VRS/CRS) becomes 87.5%, 83.7% and 100% respectively.

3.7.3 DEA Limitations

Notably, constraints of DEA application include: Non-stochastic nature (does not capture random noise). Non-statistical nature, not possible to conduct statistical test or hypothesis

regarding inefficiency and structure of production technology Inability to use quality data, the non-inclusion of capital inputs, and the inability

to measure real outputs especially those involving improvement in health status or quality of labor.

3.8 Conclusion

Various factors such as government policies, standards, norms and the technology changing patterns influence health system performance. A hospital is akin to technology, complexity and employment standards, which if procedures are not properly followed, develops ‘crisis’ in varied forms that affects the delivery process and outcomes such as quality, safety, cost and efficiency.

Monitoring these performance values is effective in the evaluation of hospitals. The above information demands validity, reliability and accuracy of hospital performance as may be possible in order to curb this non-performance ‘crises. The efficiency check on human resources, capital, materials and technology enhances capability and reduces the waste of resources, which maintains the standard and ensures the satisfaction of all stakeholders.

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Chapter 4: Research design and methodology

Chapter 4: Research Design and Methodology

4.1 Introduction

The last three chapters in this study encapsulate a review of the health system, concepts of performance, service delivery and efficiency. The research focuses on the understanding of efficient performance of the public health sector with its observable problems. The nature of analysis of these problems could be either qualitative or quantitative. Both research methods shown in figure 4.1 make use of secondary data as sources. A qualitative method involves case studies, which relies on informal interviews and observations, while a quantitative places attention on experiments, content analysis and surveys in discovering the characteristic properties of a system. Figure 4.22: Research Methods

Source: Inmarcs, 2006: Internet

Qualitative analysis proves to be the best approach in the assessment and evaluation of complex problems involving people, groups, organisations and societies, as is the case in the health sector. Various qualitative research designs include case study; biography; phenomenology; ethnography and grounded theory. These research methods are such that data collection instruments involve formal and informal, structured and semi structured interviews, observation and recording of experiences, and document verification and analysis.

4.2 Qualitative Research

Qualitative research is a form of systematic (planned, ordered and public), narrative(grounded enquiry in the world of experience where the researcher tries to make sense from the experience) empirical inquiry that is inductive in nature derived from concepts and theories. As a scientific research, it systematically uses a predefined set of procedures to answer the questions from collected evidence, producing

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findings not determined in advance, the findings being applicable beyond the boundaries of the study. It seeks to obtain specific information about values, opinions, behaviours and social contexts of a particular population, concerning emotions, and other human issues, norms, socioeconomic status and health problems.

Exploratory and descriptive are the major features of qualitative research, which uses humans in a natural setting as instruments for the data collection (Sijoe, 2009:42). This may result in an emergent design, characterised by early and on-going inductive analyses with emphasis on words rather than numbers. Qualitative enquiry happens in a natural setting with an interpretative approach. Most of the primary information is treated as taking priority above secondary information in order to avoid distortion of facts.

The researcher as an active participant and an observer synthesizes and evaluates the facts. The major reason for using semi structured information is to understand the ‘what and why’ of inefficient service delivery performance and ‘how and where’ the inefficiency originated, with a view to look into the coherence (credence), consensus (agreeing with the findings) and usefulness of the research.

4.3 Qualitative Research Methods

The most commonly used qualitative research methods shown in figure 4.2 are grouped in the third and fourth segments.

Figure 4.23: Qualitative Research Methods

Source: University of St. Gallen, 2005:2.

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Case StudiesThis constitutes an in depth investigation of an organisation, single person, social group or a phenomena within a specified time frame in a natural context using a combination of appropriate data collection devices with the purpose of richly describing, explaining, assessing and evaluating a phenomena.

PhenomenologicalThe approach investigates a group or a person’s perception of reality as the researcher constructs it with a shared meaning of experience, the reality originates in the form of emotion, relationship, or programme. It consists of semi-structured in-depth interviews that tend to locate meaningful units, linking the search themes.

EthnographicEthnography research is a labour intensive narrative research that uses multiple data collections, observations, records and interpretation of what is observed asgrounded and triangulated. It provides a great relationship between behaviour and culture. To understand the subject of reality it employs open-minded questions.Classification of codes and data enables the analysis of data, comparing the newdata collected with the existing old information.

Grounded TheoryTwo or more concepts give a theory. This research method uses a naturalist iterative data collection and relationship analysis process where the researchers derive theory from the data, which gives the expected outcome of the inquiry. The three major coding strategies employed in this type of research include open coding, axial coding and selective coding.

Focus Groups

This is panel-based research facilitated by exchange of knowledge, ideas and perspectives on a particular topic. Data is analysed like a case study. The data collection can be in such various forms as tapes, face-to-face interviews, video and telephone.

BiographyThis research mostly investigates life and experiences of individuals, as found in thearchival documents. The means of data collection include interviews and documents of various types.

4.4 Advantages of Qualitative Research

Qualitative research, apart from sensitivity to contextual matters, predominantly hasthe advantage of having the flexibility to follow unexpected ideas and so effectively explore it during the research process. Usefulness is the most important test of good

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qualitative research, being clear in understanding of a situation and free of confusion and enigma.

This study employs the use of evidence to allow readers of this research to concur with the researcher through ordered and factual findings and interpretation as there are increased opportunities for more interest from the public, government and the health system managerial teams in the findings of this study.

4.5 Basics of the research

The fundamental aspects of this research: Health in general is a complex system and even more complex is service

delivery, efficient performance and satisfaction of the stakeholders. Therefore, qualitative research is used to understand these complexities, as there are varied views on the performance of the health systems in Gauteng province.

Qualitative research accommodates a triangulation process that not only studies the system simultaneously but also acts as a check. The information from this process will indicate the level of performance and the service efficiency of these hospitals in achieving desired health outcomes.

4.6 Research Design

Research design shown in figure 4.3 involves the arrangement of components that govern the functioning of the study, which include the research purpose, conceptual context, research questions, methods and validity.

Figure 4.24: Interactive Model of Research Design.

Source: KAF Thesis Development, 2007: Internet.

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4.6.1 Research Method

This involves the conduct of the research, the approaches and techniques used in general qualitative processes of collecting and analysing of data information. It is based on theoretical approaches to investigate the research using questionnaires, interviews, participants’ observation, literature reviews, and semi-structured means of data collection.

Literature review is used to gain insight into the performance of healthcare service delivery in Gauteng province.

Interactive data collection, a valid way of data collection provides information through observing and listening to communication among groups and individuals. Meyer and Page (2005:318) state that interactive methods is a procedure adopted for effective interaction between a participant and the individual for data collection, utilized widely, particularly where there is a dearth of information in the literature review.

Unbiased and accurate, the researcher records fully the reality as is and avoids prior conclusion.

Common reference points are recorded in natural settings where variables are not manipulated and where numerous strategies exist based on a common work design. The preliminary plan drawn is flexible with the field site sampling purposefully selected, in addition to the time drawn.

Data collection analysis is by means of interviews, observations and specimen records with the iterative nature of the data forming the basis for data analysis and interpretation Confidentiality and anonymity of participants’ names remain critical.

Service quality dimensions analyse patient satisfaction, the PATH process was used to relate the service performances and verification of the data obtained, while applying DEA to find the technical efficiency (as part of the PATH process).

4.6.2 Purpose and conceptual context

In a broader sense, the research purpose introduces the means of healthcare and health systems. Referring to chapters one, two and three for the purpose and conceptual context, the purpose enables the researcher to frame the research questions to advance in accomplishing the objective of the study, assists in identifying an anticipated phenomenon, influences and generates new-grounded theories, such as understanding the process in which the events take place. The research questions assist in the correlation of the purpose and conceptual text and give guidance on how to conduct the study (in this case the relationship to methods and validity).

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Major questions were based on performance standards, efficiency rating, gaps or disparity between public and private hospitals, factors affecting the variables and outcome quality. For convenience, all questions concerning efficiency of healthcare performance concentrated on quality of service dimensions and health outcomes. The questions helped to check the available and utilisation of capacity, use of innovation and information systems and the efficacy and effectiveness in the service delivery process.

The choice of questionnaire option was due to its simplicity and its inexpensive means of obtaining accurate information from large population groups, permitting anonymity, which may result in response that is more honest. If well designed, this method eliminates bias, since the researcher is not present. However, its dependency on personal reporting, which may be biased or inaccurate constitutes a major setback in using this option (Anwases, 2007:109). In lieu to this, the nurse managers granted the researcher face to face interviews while other respondents filled out the questionnaires.

Based on the group’s contributory influences to the performance and efficiency of the healthcare service, the formulation of the questionnaire differs for each group, taking each group approximately 10 to 15 minutes to complete. Closed-ended questions mostly were used to measure opinions, reactions and attitudes of patients’ perception and expectations on health service delivery.

Major constituents of the questionnaire included variables (inputs, outputs and outcomes) derived after a thorough analysis of the literature review guided by the research objectives and conceptual theories that resulted in the development of structured questionnaires numbered A-H (refer to Appendix F) with the common aim of determining the performance efficiency of the public hospitals. Each section in the questionnaire contains participant’s views on the causes and problems affecting healthcare service delivery, with questions on suggestions of possible recommendations that could assist in alleviating this crisis and improving service delivery.

Section A is the common demographic data for all the respondents. Forty-one (41) patients respondent participated in the 13 questions of section B on patient centeredness (perception and expectations) namely timeliness of care/responsiveness, empathy, tangibility, and safety. Eighteen (18) questions of section C were given to 26 doctors and 30 nurses respectively. This group answered the questions, based on their use of innovation, healthcare approaches, integrated information systems, clinical effectiveness, responsiveness, and service utilization. Section D which formed the bulk of the questionnaire, comprised 30 questions for the five nurses’ managers, with focus on governance (leadership), staff orientation, and

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the use of integrated information systems, service availability, utilization, patient centeredness, and health outcomes. Included in this group D questionnaire are issues related to government policies and strategies, causes and problems facing efficient service delivery and possible suggestions to government on ways to improve service delivery within the public healthcare sector. Seventeen (17) pharmacists/assistants responded to Section E questionnaire, which consist of 11 questions on responsiveness, clinical effectiveness, information systems, safety, and timeliness of care, service availability, hospital utilization and capacity, formulated as it affected their perspective. In Section H, five questions on cleanliness of the facilities and its associated problems were submitted to 20 cleaning staff, while section F dealt on major safety issues on safety of patients and staff, theft, violence and the use of electronic monitoring systems in the facilities, handed to 12 security officers.

4.6.3 Validity

Maxwell (2005:4) describes validity as a component of the research design that consists of strategies to identify and to rule out alternative explanations (threats) which depend on the relationship of the conclusions to reality, leading to the possibility that the research may be inaccurate. Validity checklists explored in this research include a collection of information from a wide range of individuals and settings (triangulation), comparison of the information, respondent validation (e.g. participants feedback), and the use of and search for discrepant evidence or negative cases.

Data CollectionOpen ended and semi structured questionnaires served as the most appropriate instrument to gather data through formulated questionnaires guided both by the objectives of the research and the literature review. These were delivered to the nursing manager of each of the hospitals. The researcher initiated contact to meet the respondents with the help of the Managers.

For comparative analysis, the public sector benchmarked an excellent private hospital. Three sampled hospitals (district, regional and private) and one PHC (N=4) of the same demographic confinement were targeted that have direct activities with the patients. The consent form was used to explain the purpose of the research and to seek the solicitation of respondents’ assistance. The participants answered not all the questions. Out of the 200 Questionnaires handed out of the 78 questions, 154 of this came back, resulting in a response rate of 77 per cent.

Data AnalysisData analysis is the synthesis of the processed information collected, which gives

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meaning to the research data, presenting the views of the respondents regarding their perception on the nature of service and performance of Gauteng hospitals. Comparatively, analysis was carried out in the areas of patient satisfaction, service utilization, resource allocation, the use of integrated information systems, service gaps between the public and private sectors (especially to the extent of implementation of information technology) and the influence of the policies and strategies in the use and allocation of resources. The variables used in the analysis of technical efficiency consisted of the inputs and outputs, indicating the capacity and utilisation levels of the hospitals under study.

The research utilised inputs (physical) doctors, nurses, patients, clinical facilitators, pharmacists, laboratory technologists, hospital managers, and bed capacity (capital). The outputs are the results of the inputs resulting from the combined interaction of human resources, workforce objectives and health system performance. This study assumes that the control of hospital facilities is limited due to the volume of their outputs and no link existing between outputs and staff remunerations therefore incentives, which may propel the services in an extraordinary way, is assumed non-existent or constant. The outputs included admission, OPD visits, hospital discharges (excluding deaths) and child delivery. However, the choice of two inputs and three outputs from each hospital and health centre was guided by the variables common to the hospitals. The health centre (PHC) was not analysed in terms of efficiency, as there was no peer for comparison; however, it was included in every other performance assessment.

The value of healthcare services lies in its capacity to improve its outcomes for individuals, achieved through low wastage of resources (efficiency) and attainment of high goals. To understand the outcomes clearly, the questionnaires tracked medical records, focusing on the health services such as re-admissions and mortality rates.

The research looked for patterns, anecdotal and other evidence and interpreted them by means of logical deductions and indications as depicted by the collected data through the collaboration of different respondents. The satisfaction of the needs and wants of the stakeholders finally enabled this research to validate the identified service delivery issues and problems, leading to the recommendations.

4.7 Conclusion

This qualitative research used structured and semi-structured, open-ended questions in its sampled population of three hospitals and a clinic. Data collection was by means of face-to-face interviews and questionnaires targeting patients, hospital management, and technical and support staff to create and to establish a baseline from which to monitor the performance efficiency of the Gauteng healthcare system.

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5 Chapter 5: Results

5.1 Introduction

This chapter represents the views of the respondents on performance efficiency of the public healthcare sector. The results embodied are on technical (outcome) and functional (process) performance measures (PATH process) of service quality dimensions. Thereafter, it is narrowed down to the technical efficiency of these health facilities compared to the private sector to show its relative efficiency.

5.2 Demographic Data

The demographic profile of the respondents are based on age, level of position, gender, level of experience and education that were facilitated in the interpretation of the results.

PatientsChildren, young adults and adults dominated as the respondents, with the female gender constituting 75% and males 25%. Thirty-two (32) of the 41 patients participated in the public healthcare sector. Seventy- six (76) per cent are within the age of 25-50, 18-24 (14%) and over 50 (10%). The Black race (82%) overshadowed the population sample, with White at 2%, Coloured 11% and Indian 4%. Ninety per cent (90%) have matric or below as their level of education; 10% have a diploma or higher education. Over 95% are unemployed; 4% claimed to be doing menial jobs and only 1% being working class. This data concurs with the literature findings that young people, women, more vulnerable citizens and low-income earners predominantly use public healthcare sectors. In the private healthcare sector, of the nine participants, 96% are working, 2% are unemployed and 2% are students. The Indian race dominated with 50%; Coloured 30%; White 10% and Black 10%. A hundred per cent (100%) of the sampled participants have a diploma or a higher degree, which shows that a more privileged class utilise the private healthcare facilities.

DoctorsIn the public healthcare sector, of the 18 respondent doctors, 70% are predominantly of Black origin, 10% White and 20% Indian. Fifty per cent (50%) are mostly interns and those with less than 5 years of experience, 30% have experience of less than 10 years with an honours degree qualification, 20% have more than 10 years of practice (with less than half being specialists with a Master’s degree). 50% are within the 25-35 age range, 30% between 36-50 years and 20% over 50 years. These statistics agree with the literature that the doctors are mostly interns that utilise a trial

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and error method of healthcare approach compared with evidenced and experienced clinicians, with few specialists found in the public healthcare facilities.

Of the eight participants in the private healthcare sector, 40% are Black, 40% Indian, and 20% White. A hundred per cent (100%) have a Master’s degree qualification (specialist). Eighty per cent (80%) are predominantly between 36-50 years of age and have over 10 years of experience, concurring with the literature review that more specialists and evidenced based experience doctors dominate the private sector; this is partly the reason for a high quality of care and the uncompromised cost of service.

NursesThis is a female dominated profession of 95% and a mere 5% male. Of the 24 nurse respondents in the public sector, 90% have diploma qualifications and 10% have degrees. Sixty (60%) per cent are aged 36-50 years, 25% are more than 50 years old and 15% are between 25-35 years. Fifty-five per cent (55%) have less than 5 years’ experience, 30% 5-10 years and 15% have 10-25 years of experience. These frontline staff is relatively experienced, however, interns still dominate and as such, a waste of materials and service failures abound due to overall inadequate supervision, as documented in the literature review.

A total number of six nurses responded in the private sector. Nurses aged 36-50 years constitute the majority (70%), 10% (more than 50 years old), 20 % (18-25 years). Of this age, 80% hold diploma qualifications and 20% degrees. Sixty-five per cent (65%) of these have 5-10 years of experience and 20% have 10-25 years, 10% got less than 5 years and 5 % have more than 25 years. This information supports the findings that experience and level of education give quality of care, minimisation of waste and confidence in service satisfaction.

Pharmacist/AssistantsOf the 10 respondents from the public sector, 60% are Pharmacists and 40% Pharmacy Assistants’ with degrees and diploma held respectively. Only 40% have more than 10 years of experience, 20 % (less than 5 years) and 40% (5-10 years). Eighty per cent (80%) of this group is within the age of 25-50 years and 20% above 50 years. In the private sector, three (3) out of seven (7) of the respondents are Pharmacists and the rest are Pharmacy Assistants. Five have more than 10 years of experience, and 2 less than 5 years. Both sectors of pharmacists strive in maintaining high patient centeredness as their demographic data does not show much disparity and with no evidence found in the literature to contradict this.

Nurse ManagersThe five Nurse Managers aged between 36 and 50 years are female dominated, In addition, they have experience that spans more than 10 years in both healthcare

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sectors. In the public health sector, three of four have degree qualifications while the private sector nurse manager had a master’s degree qualification. No disparity of information was observed.

Supporting staffThe three selected groups of supporting staff are made up of 10 Cleaning Staff, 10 Security Staff and 11 Laboratory Staff. Eighty per cent (80%) of these are female and 20% male aged between 25-50 years. Seventy per cent (70%) of the laboratory staff have degrees and 30 % diplomas. All the security staff has certificates except two with higher degrees, and the Cleaning Staff with other unspecified qualifications in both sectors.

5.3 Service Indicators

These represent the results obtained based on PATH process dimensions and requirements.

5.3.1 Nature of Service and Patient centeredness (Satisfaction)

Patient respondents in public and private healthcare facilities answered Section B of the questionnaire numbered 1-13. These questions were asked based on their perceived service experience while using these facilities. Section C questions number 2 (Medical Personnel) and in Section D number 21 (Nurse Managers) questions were asked for the most improvement in patient satisfaction and the most compelling reason for their organisation to improve patient satisfaction respectively.

Public Healthcare Respondents Seventy-six per cent (76%) of the public healthcare patient respondents felt dissatisfied due to long waiting time of 2-3 hours to see the doctors, with 1-2 hours for collecting test results and 1-2 hours for medication. Poor handling of the queue is common. Most of the public healthcare patient respondents felt that there is difficulty in getting appointments with doctors within certain specialities such as neurologists, pulmonologists or cardiologists. In addition, they cited problems encountered such as rudeness of staff, sometimes having to redo a test due to non-availability of earlier results, no respect for their privacy and doctors being in such a hurry that they do not listen carefully to patients. Public healthcare patient’ respondents confirmed that there is easy access to the medical personnel, that the facilities appear to be clean but noted the utilization of obsolete equipment. Most of the public healthcare sector respondents (89%) accepted that they were never denied treatment even when they had substantial outstanding financial bills. They also agree that their health outcomes were explained to them beforehand. However, 21% of primary healthcare (PHC) sector patients complained that security officers turned them away 2 hours before

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closing time. The public healthcare sector Medical Personnel respondents insist that hospitals and managed care plans are the areas that needed the most improvement while the Nursing Manager respondents stated that the fear of damage to the facilities’ reputation is their most compelling reason to improve patients’ satisfaction.

Private healthcare respondents Most of the private healthcare sector respondents complemented the cleanliness of the facility with its modern equipment stating that the hospital is in good condition. Privacy is respected, and the competency of the doctors were never doubted, emphasising that enough time is taken in listening to their needs during consultations. Access to medical personnel is easy; there are no lengthy waiting times for collection of test results and medication. Medical aid schemes are accessible, and getting treatment from speciality doctors was never a problem with a good system for handling queries. However, a few private healthcare sector respondents (8%) felt dissatisfied. They complained of receiving tests and treatments that were probably not necessary, this may be due to the availability of their medical aid fund.

Summary Delays in obtaining an appointment and long waiting times are evident (2-3 hours on the average) while seeking and receiving care in a public facility. The lack or failure of timely care denies patients of critically needed services. Clinician’s inaccessibility to patients due to a lack of integrated and enhanced track of patient’s information agrees with the literature findings of Gauteng provincial healthcare information and supports Shih et al. findings that due to a lack of electronic medical record system in place, health conditions and outcomes worsen. A dissatisfaction rate of 76% agrees with Statistics SA results of service failure in public healthcare facilities. Although hospital facilities are clean, the obsolete equipment and enabling environment may affect performance of staff in delivering the good services evident in the conceptual theories. Overly rushed medical personnel make patients perceive the Clinician’s behavior as an indication that their health problems are not a priority. This is partly caused by the population surge, low staff-patient ratios and the prevalence of violence and injuries as indicated in the literature. The communication gap between patients and the clinicians and between the hospital management and clinicians, led to patient dissatisfaction, neglect and often-medical errors on the part of personnel. This is part of the deserved reasons for a lack of confidence of the public in government healthcare facilities found in the review of literature.

5.3.2 Service Availability and Resource Allocation

Various questions (Section B: 11; Section C: 10; Section D: 11 and Section E: 4, 5 and 10) on service availability and allocations of resources were respectively posed

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to Patients, Medical Personnel, Nurse Managers and to the Pharmacists of both public and private healthcare respondents.

Public healthcare respondentsThe Medical Personnel of public healthcare respondents pointed out that the average waiting hours of patients to see the doctor ranges between 2-4 hours, 2 hours to get test results and 1-2 days to get results sent to the referral laboratory while it takes 2-3 hours to get medication. Public healthcare Medical Personnel and Nurse Manager Respondents affirm that through health education, chronically ill patients are continually supported. Additional to this, the district and regional hospitals refer the patients further to their local clinics for closer monitoring and for immediate medical attention as demanded. On the issue of availability of essential drugs, its shortage and replacement, public healthcare Pharmacists’ respondents emphasise that these occur regularly (almost on a monthly basis) and time taken to receive replacements is indeterminable, sometimes it takes weeks or months. They attributed the problems with drug supplies to theft in the facility, wastage on the part of patients probably caused by over prescribing and improper record keeping of drug information. However, these respondents suggested the use of motivation forms, TPH 36 forms and a scheduled drugs register to control medication and to minimise abuse.

Private healthcare sector respondentsThe Patients’ respondents expressed confidence in having easy access to speciality doctors. They indicated an average waiting period of 15-45 minutes for consultation, 10-30 minutes for test results and less than 15 minutes to collect medication. In affiliation with other NGO, the private healthcare Clinicians and Nurse Manager Respondents attest that chronically ill patients are given health education along with their family members, and offer closer monitoring of patients. On drug waste and shortage, private healthcare Pharmacists’ respondents indicated that such experience rarely occur due to the well-coordinated and integrated system that monitors the disposal of drugs. This helps in taking earlier informed decisions to replace the drugs.

SummaryThe public Clinicians agree with the patients that long waiting times exist and medication supply often is not regular and prompt due to wastage and over prescribing of the dosages. This supports the literature evidence that theft, poor decision-making, a no team-based service approach and lack of integrated information system underpins the utilisation of services in public healthcare facilities.

5.3.3 Facility Capacity and Service Utilisation

The degree of utilisation of the healthcare sector tremendously affects its capacity.

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Various questions were posed to the Medical Personnel and the Nurse Manager respondents of both the public and private healthcare facilities. Questions on Section C (5, 8, 9, 15, 17, and 18) and Section D (2, 14) focused on the capacity of the facilities. Questions on Section D (1, 6, 7, 8, 9, 10, 13, 16, and 20) for the Nurse Managers targeted the facility’s level of utilisation. Public healthcare respondents Due to their different levels of care, the healthcare facilities had different results. The bed capacity of the district and regional is 280 and 537 respectively. PHC has no in-patients. The overall staff employed by district is 475 (nursing staff 247; Doctors 24; Pharmacists 4; and supporting staff 200), the regional 621 (nursing staff 403; doctors 57; pharmacist 9; and supporting staff 253), PHC 173 (nursing staff 57; doctors 13; pharmacist 1; supporting staff 102). However, the respondents gave very close answers, stating that it takes at least a day to obtain basic laboratory results of test samples on syphilis, TB and other major tests. On a daily average, the minimum number of patients assisted by each medical staff member is less than 50 during summer and above 50 in winter. The ratio of staff (nurses and doctors) to patients in PHC is 1:30 and 1:40 respectively; district (1:20 and 1:30) and regional (1:20 and 1.30). These respondents insist on an increase in the population, perennial shortage of staff raising their workload, increased staff burn out, negligence on some patients and occurrence of medical errors. These respondents’ suggest that patients should make use of better health related choices and better financial planning to improve their healthcare outcomes, which will help in decongesting the number of people visiting the public healthcare facilities daily.

PHC and district level respondents are of the view that their facilities mostly are utilised by 70% adults, 10% young adults and 20% children. The respondents stated that a record of over 240 and 400 safe deliveries respectively take place monthly; 300 and 600 under 5 are immunised; over 200 and 250 women attend antenatal 1+ monthly, respectively in the district and PHC. The district public healthcare respondents believe that the average monthly number of admissions and discharges are 1180 and 520 respectively. The number of discharges compared to the admissions demonstrates the occurrence of a longer length of hospital stay evident in the public healthcare sector. The public healthcare respondents from the regional hospitals claimed 90% adults and 10% young adults mostly use the medical ward facilities and this causes longer lengths of stay. The PHC outpatients according to its public healthcare respondents are more than 22500 in number on monthly average. In over 20% of the public healthcare respondents, in-patients return to the same unit for a related condition of illness within a period of 28 days due to patients’ non–adherence to treatment advice and medical personnel not explaining patients’ conditions to them properly. They advise that patients must be empowered by

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making them understand their conditions, changing their lifestyle patterns and taking treatments as prescribed.

Private healthcare respondentsThe healthcare facility has a bed capacity of 365 with the patients occupying over 65% of this monthly. The total number of staff (excluding the supporting staff) is 511: Nursing Staff employed including the Agency contracted is 384. One hundred and twenty (120) Doctors and seven (7) Pharmacists rented its facilities. Depending on the type of test, most tests results take less than 45 minutes to be received by the doctors while procedural tests such as TB and syphilis takes several hours for the results to become available. The minimum average number of patients assisted by each doctor is within the range of 10 or less (1:10) daily while each nursing staff attends up to 15 patients (1:15) daily. The facility according to the Nurse Manager is still short staffed of Registered Nurses in Trauma and Theatre Units.

Private healthcare respondents believe that close to 3930 patients use the facilities monthly, the average monthly number of admissions recorded in its facilities, and discharges are 3800 and 1990 patients respectively, showing more than 50% discharges per month. Of these numbers, the adult patients constituted 80% and young adults and children 20%. However, the trauma and maternity patients are over 130 in number. Less than 5% of the patients return to the hospital for a similar illness within a 28-day period.

SummaryCapacity of the public healthcare facilities is affected negatively due to increased workload, high mortality among patients, shortage of staff and working with difficult patients. Literature evidence states that public hospitals struggle to fill existing medical posts complicated by a decrease in enrolment of nurses in government health institutions. The 20% readmission within 28 days, contrary to 17.6% in the literature, is a clear indication that health conditions are deteriorating. This is partly due to the HIV/AIDS pandemic, resurgence of TB, pneumonia, diarrhoea, and increasing population density resulting in a negative performance standard.

5.3.4 Information Systems and Technology Innovation

Technology innovation and an integrated information system play an important role in every area of healthcare. Most of the respondents received questions on the influence of this process. Questions on Section B number 12; Section C (6, 7 and 14)and Section D (26, 27 and 28) were asked to the Patients, Nurse Manager and Medical Personnel respondents.

Public healthcare respondents

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The Medical Personnel respondents revealed that the chronological health history of a patient is not traceable once the file is lost. If this happens, most of the important test results are also lost; consequently, the tests must be repeated. Patients’ respondents of level one and two of the public healthcare respondents complained that they waited a longer time to retrieve their files stored in shelves and sometimes, these files were lost. The medical personnel respondents confirm that patients wait as long as one hour to get their files, which sometimes are not found resulting in rescheduling of the patient’s appointment. The loss of chronological medical histories and previous prescriptions, leads to patient frustration, a waste of time, incoherence in treatment, burnout of the medical staff and a waste of limited resources. The laboratory staff also indicated that there are no discernible means for the doctors to track the test results. One of the Nurse Managers’ Respondents remarked that “We are still waiting for the installation of the computers that was promised severally for some years now”, another respondent added, “and the so called e-prescribing system we never heard of it before” The medical respondents remark that the installation of technology, application of recent innovations and the use of an integrated information system will enhance the effectiveness and efficiency of their service.

Private healthcare respondentsMost of the private healthcare patient respondents stated that the waiting time was never long; files were easily traced with their previous tests results handy. The medical personnel indicated that they use electronic filing, files packed in shelves and other means to keep patients information and records. The respondents while emphasising the usefulness of technological advances indicated that they also use electronic means to track tests results; this influences their performance in delivering efficient services. However, the Nurse Manager indicated that they are not yet using the e-prescribing technology but uses ‘VON’, a live network forum to stay up-to-date with new standards of care to benchmark their existing core standards.

SummaryThe above supported the literature findings that there is no reliable means of tracking patients’ information and records in public hospitals and clinics, contrary to the theorised concept that achieving the best service practice and for self-healthcare management, a resourceful integration information system that will also exchange data electronically, is vital. The concept also indicates that a lack of relevant clinical knowledge and patient information forces most Clinicians to rely exclusively on trial-and-error methods contrary to personalized and evidence based medicine that increases the probability of safe and effective healthcare delivery due to enhanced technologies.

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5.3.5 Governance (Leadership)

Leadership constitutes the pivot that rotates the healthcare service sector. Poor governance creates space for performance inadequacies and inefficiencies that result in poor service delivery. The Nurse Manager responded to questions on Section D (Numbers 21, 22, 23, 24, 28, and 29) while the Medical Personnel respondents answered questions 3 and 4 of Section C.

Public healthcare respondentsOn how leadership drives capability in fostering efficiency and effectiveness across the healthcare sector, public healthcare respondents’ state that staff is empowered through in-service training and are encouraged to further their studies in their respective careers. To optimize efficiency in healthcare, training and recruitment of the youth into the health profession is advocated. The respondents insist that staff motivation and retention is a priority of the government, however, the concept of avoidance of waste is not fully institutionalised in the public healthcare service. They indicated that the biggest problems facing public healthcare facilities are the frequent out-of-stock of drugs and non-integrated information systems to monitor the quantity of drugs supplied and dispensed. The procurement processes of these essential drugs and other materials escalate expenditure beyond proportion; late coming and absenteeism of staff; shortage of staff; poor and obsolete equipment and dilapidated infrastructure were also mentioned. Public healthcare respondents claim that their facilities work with NGO’s as a follow up to track the condition of discharged chronically ill patients who needed homecare.

Private healthcare respondentsPrivate healthcare respondents stated that the organisational structure of private healthcare streamlines the functionality of the units, which included timely and well organised procurement processes; training and retraining of staff and co-ordinated and integrated information systems. Private healthcare respondents emphasised the seriousness of absenteeism and lateness and that management does not comprise this for anything. However, there still exists a shortage of staff especially in Trauma, Intensive Care Units and Theatre in the private healthcare facility.

SummaryAlthough staff empowerment through in-service trainings is available, the literature review indicates that enrolling institutions restrict admissions, in addition, the enabling environment and conditions of service for the existing ones is inadequate. These findings agree with the literature that the concept of waste is never institutionalised in public healthcare facilities and absenteeism and lateness remain serious issues. The information also concurs with the literature findings that drug shortages and the rising cost of services are common, indicating that it is the

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aftermath of leadership poor managerial decision making, and non-coherent procurement processes.

5.3.6 Government Policies and Strategies

The questions on Section D (numbers 22, 23, 24, 29 and 30) were used to understand the influence of government policies and strategies on healthcare service delivery. The results from all the Nurse Managers came out with almost the same answers from all the respondents. Public healthcare respondentsGovernment termination of some NGO partnered services increased the ‘crowdingeffect’ experienced in public hospitals. These respondents lamented that most public doctors and nurses invariably share their work schedules with the private hospitals either due to better working conditions or as a means to make ends meet. Financial policies on free health services especially the non-payment of gynaecological, maternity and child health services are abused by citizens and more by foreigners, especially the numerous asylum seekers in South Africa. A pregnancy termination policy encourages abuse of resources. A poverty alleviation policy promotes dependency on government, lack of interest to work by the young mothers and excessive abuse of services in areas of grants and baby foods. The deployment of political cadres with no professional health experience results in the poor performance of most public health hospitals. The outcomes of poor decision making abilities and co-ordination gives way to frequent shortages of essential drugs, lack/shortage of equipment and facility maintenance, abuse of financial resources, denigration and a shortage of staff.

Private healthcare respondentTo enhance service delivery in public healthcare facilities, the Nurse Manager of the private healthcare facility advise government to offer the public healthcare workforce, especially the medical personnel, with risk management training course in order to correct the reoccurring errors persistent in public healthcare facilities; to revisit most of its strategies and policies; to listen to peoples complaints and to pay suppliers on time for their services. The respondent cited examples of her private hospital’s services rendered to public hospitals that amount to several million Rand, which is still outstanding. In her words, ‘I cannot imagine how we would be able to continue rendering services to these public hospitals with such accumulated unsettled debts spanning for several years from the government’. The delay and the inability of government to pay suppliers for the services rendered to public hospitals and clinics results in the private healthcare sectors reluctance in accepting further rendering of specialty services of critical and emergency nature to the public health sectors.

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DiscussionRegrettably, the implementation of several policies and strategies either have not been correctly followed due to inadequate process and procedures or are marred by unavailability of an integrated information system and incorrect use of innovation. The literature findings agree with the respondents’ information for the revalidation of some government policies. The findings above concurring with the literature and theoretical concepts, indicate an urgency in establishing care co-ordination networks, care management services, policy guidelines on standardised wages, technical emphasises on resource management, decentralisation policies, termination and poverty alleviation policies, reinforcement of its operating standard and creation of proactive strategies and safety rules.

5.3.7 Health Outcomes

Questions on Section B (number 5), Section D (numbers 3, 4, 6 and 9), and Section H (numbers 2, 3 and 4) were posed to the patients, Nurse Managers and Laboratory Staff to access the possible health outcomes obtainable within their healthcare facilities.

Public healthcare respondentsThe respective Nurse Managers respondents for district and regional hospitals estimated the average number of deaths recorded monthly in their facilities as 48 and 80 respectively (HIV/AIDS related diseases 20 and 40; pregnancy 2 and 0; chronic diseases 20 and 40; infants under 5 years 4 and 0 in that order). The average monthly percentage number of in-patients discharged that return to the same unit for a related condition of illness within a period of 30 days is 25% and 21% hospital level 1 and Level 2 in that order. The average number of safe deliveries recorded monthly in PHC and level 1 is 240 and 400 respectively.

Private healthcare respondentsThe average number of deaths recorded monthly in the private hospitals is 23 (HIV/AIDS related 13; pregnancy 1; chronic diseases 9; infants under 5 years 1). The number of in-patients discharged that return to the same hospital for a related condition of illness is 15% while the average number of safe deliveries recorded monthly is slightly above 240.

DiscussionThese empirical findings concur with the health assessment findings in the literature review that burden of diseases is heavy on South African hospitals with low health outcome, especially with HIV/AIDS and TB related dreaded diseases and chronic diseases as the major causes of deaths in South Africa. Infant mortality and maternal morbidity remains high. The findings above support the health assessment review

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that the MDG 2015 targets seem unrealistic to achieve with this trend of health outcome.

5.4 Result Analysis

Using Performance Analysis Tool for quality improvement in Hospital (PATH) The interpretation of the survey results in the three public and one private healthcare facilities based on PATH quality dimensions with a closer focus on technical efficiency are as follows:

Patient SafetyMedical errors are prevalent across all public healthcare settings. The problem is not a lack of dedication to quality care by health professionals but due to a lack of systems that prevent medical errors from occurring. Problems of burnout of staff are due to low staff-patient ratios; absenteeism; the use of interns (who practice trial and error methods on patients in most services that demand professional evidence based experience); ineffective security and information systems and communication discrepancies between health professionals and management and between patients and health professionals. Patient safety in private healthcare is relatively better; this is evident in the presence of speciality doctors and an effective communication network, enhanced with current security systems and gadgets.

EffectivenessThe expectation of every clinician is to have improved outcomes, diagnosis and to use scientific evident treatment to improve patient’s experience and likelihood of desired health outcomes. In the public healthcare facilities surveyed, the health outcomes differ probably due to infrastructural and technological inadequacies, worsened by a greater number of individuals who are unable to afford private healthcare services. In the private sector both personalised and evidence-based treatments exist harnessed by updated technological innovation culminate to the desired health outcomes.

Responsive GovernanceDelays in obtaining appointments and long patient waiting times are evident while seeking and receiving treatment in the public healthcare sector, partly attributed to lack of integrated information systems. Failure of timely care results in patients losing of confidence in the public healthcare sector. Long waiting times allow health conditions to digress and outcomes to worsen. These problems could be linked to managerial incapability in matching the population’s demand to its capacity and resources. A major contributor to this problem is the appointment of people based on political status quo in place of professionally competent personnel. The cause-effect is weak decision-making and snail speed actions in matters of extreme health nature.

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Patient CenterednessPatient’s needs, values and preferences are essential to providing high quality care. Physical comfort exists to some extent in the public healthcare facilities. The existence of basic amenities attest to this but inevitable emotional support is rarely observed due to poor channels of communication between patients and healthcare workers unlike in the private sectors. Access to speciality doctors is difficult. Delays in the collection of test results and long waiting times to consult with the doctors depict the unreliability of the public healthcare sectors. Unequal treatment in the care received by any of the ethnic populations in the public hospitals is found to be the same.

Staff A shortage in medical personnel is common in both sectors but serious in the public healthcare sector, in spite of the huge financial involvement of government and private sectors in training and retraining of the healthcare workers. The severity of staff shortages is complicated by burden of diseases, population explosion, injuries and violence. Absenteeism and staff turnover remain major issues in the public healthcare system, dragging service delivery backwards.

Technical Efficiency Table 5.1 shows the results of the variables selected indicating the technical efficiency of the surveyed healthcare facilities.

Table 5.11: Hospital Variables


The relative efficiency of the district and regional hospitals benchmarked to the private hospital (Efficient frontier) in an input oriented efficiency shows the extent hospitals could economise their inputs usage without altering their outputs.

To estimate the efficiency of each hospital (table 5.2), each of the outputs is divided by their corresponding inputs to obtain the hospital with the highest ratios. The higherthe ratios the more efficient the hospital is. The frontier formed by the best practice

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healthcare institution ‘envelops’ all other (inefficient) institutions in the group.

Table 5.12: Efficiency Ratios of the Hospitals


The best results attained estimated assuming CRS shows district 40%, regional 63% and private 100%. These public hospitals are relatively technically inefficient in comparison to the private hospital. The efficiency depicted by the total staffed beds not the physical beds may not be more accurate to measure the hospital’s total capital, as the physical beds categorise the level of activity.

Often, health services production processes are not linear, thus assuming variablereturn to scale (VRS), the estimated efficiency scores becomes 65%, 71% and 100% respectively, for the district, regional and private hospitals. This finding implies that if the district and regional hospitals were to operate efficiently, they are capable of producing their current output levels with 59% and 26% less input endowments than they are currently using. Their scale efficiency score becomes 92% for the district, regional (52%) and private (100%). The private hospital is operating at its optimal size while the public hospitals are scale inefficient for not operating at their most productive size for the observed input mix.

Figure 5.25: Production Possibility Frontiers indicating the Efficiency Trend Using the Input / Output mix of the Hospitals


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Chapter 5: Results

The health outcomes clearly reveal that re-admission of patients within a 28-day period are 25%, 20%, 21%, and <5% for PHC, District, Regional and Private hospitals respectively. The PHC figure depicts the nature of demand overstretching primary healthcare facilities. The results from these facilities could partly be attributed to experiential effectiveness and commitments of the clinicians, choice of health approach, and use of innovative technology, communication network, lifestyle patterns and income levels. The private hospital also recorded the least number of deaths with the highest occurring in regional hospitals possibly attributed to burden of diseases in addition to the above named reasons.

5.4.1 Service Gaps between Public and Private Healthcare Sectors

From these results and deductions, notable service gaps existing between the public and public healthcare facilities are as follows:

Most doctors permanently employed by government spent most of their work hours in private hospitals, probably, due to attractive remunerations and better working conditions.

Medical funding, change of lifestyle patterns and culture set the public and private healthcare sectors services apart. The unemployed, vulnerable and low-income earners (who constituent the majority of the population) use the public health sector, exerting pressure on the all-ready overstretched available resources. The privileged class and high-income earners who receive adequate medical funding prefer the private sectors excellent services to that of the public sectors.

Although private and public health sectors have quite experienced doctors and nurses, a discernible number of inexperienced / intern nurses and doctors are found in public healthcare sectors.

Most private facilities are funded and updated regularly with modern, clean medical equipment, the opposite of which is the case in public healthcare facilities, which has obsolete technology infrastructures, hampering the services of the medical personnel in these facilities. This creates the demand for private healthcare services by the over stretched public hospitals in extremely critical cases.

Absenteeism, late coming and staff shortages in public hospitals are common, resulting in long patient waiting times, delays and sometimes, medical errors. A means of controlling these issues exist but with no discernible enforcement is in place.

Excessive hospital lengths of stay abound in public hospitals compared to the private hospital used in this study, partly due to the no fee for service and relatively low payment for service policies; this has led to excessive and abusive use of resources by the public.

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Chapter 5: Results

5.5 Conclusion

The public healthcare sector does not produce the best health outcomes or the highest levels of satisfaction compared to the private sector, despite the huge resources invested in it. Waste and inefficient provision of health care services are pronounced. Increased expertise and increased resources will not alone translate to the quality of healthcare that individuals expect. Organizing the delivery of care and making informed decisions is paramount and inevitable.

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Chapter 6: Conclusions and recommendations

6 Chapter 6: Conclusions and Recommendations

6.1 Introduction

Efficiency cannot reasonably be assessed without reference to quality. Efficiency, quality and performance remain serious concerns in any healthcare system. In a well-developed, well-resourced health system, the expected outcomes cannot predictably be achieved even with wide variations in standards of healthcare delivery.

No single cause of inefficiency and ineffectiveness emerged, yet the causes seemed obvious. Stakeholders demand more costly care than would technically be efficient. The effort to increase efficiency through elimination of ‘waste’ has largely failed.

6.2 Performance Recommendations

Based on the results and the analysis made from the quality of care findings and its problems, the following recommendations could improve the health outcomes, and the performance efficiency of the Gauteng public hospitals. Everyone owns a piece of the inefficiency problem and therefore of its solutions.

Table 6.13: Performance Recommendation

Subsidiary Objectives

Research Findings Recommendations

Objective 1

To understand the nature of service and performance level of Gauteng public healthcare sector in areas of patients’ satisfaction

Delays in obtaining an appointment and long waiting times are evident (2-3 hours on the average) while seeking and receiving care in a public facility, this failure of timely care denies patients of critically needed services.

There is Clinician’s inaccessibility to patients, possibly due to shortage of speciality doctors and lack of electronic medical record system in place, as such health conditions and outcomes worsen.

A dissatisfaction rate of 76% is an evidence of service failure in public healthcare facilities.

Hospital facilities are clean, but obsolete equipment and non-enabling working environment affect performance of staff.

Enhance communication links among all healthcare stakeholders.

Ensure that drug supply is regular and prompt.

Update infrastructures and revamp facilities regularly.

Match demand with capacity.

Clinicians should listen to patients’ complaints.

Encourage doctors and nurses during their training to be passionate in the care of patients

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Overly rushed Medical Personnel make patients perceive the theirbehavior as an indication that their health problems are not a priority.

Non engagement of patients and loose communication gap existing between patients and the clinicians and between the hospital management and clinicians, led to patient dissatisfaction, neglect and often-medical errors on the part of personnel, resulting to lack of confidence in public healthcare facilities.

Patients’ safety is compromised due to lack of systems that prevent medical errors from occurring.

Objective 2

To indicate the extent, influence and the use of e-service and information access in the public healthcare facility.

There is no reliable means of tracking patients’ information and records in public hospitals and clinics.

There are no resourceful technologies and integration information system that exchanges data electronically in terms of relevant clinical knowledge and patient information, which will enable the clinicians achieve best service practice and for the patients to imbibe a self-healthcare management.

Referrals are not effectively enforced due to lack of e-service, encryption of data from one hospital to the other and non-homogenous information system of Gauteng hospitals and Clinics.

Regularly setup and update an effective and well-functioning integrated information system, harnessed by information workshops for the clinicians to emphasise on the need for e-service.

Linking hospitals and clinics will make easy access to patient information and will enforce the effectiveness of referrals and reduction of waste in the prescription, use, and abuse of drugs by the patients.

Training and retraining of service providers is essential.

Based on common healthcare problems, evidenced and personalised care and treatment approaches should supersede anyother method.

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Objective 3

To review the extent of Service availability, facility capacity, resource allocation and utilisation in the public healthcare sector

The public healthcare Clinicians agree with the patients that long waiting times exist and medication supply often is not regular and prompt due to wastage and over prescribing of the dosages.

Theft, poor decision-making, Vandalism, fraud and lack of integrated information system underpins the utilisation of services in public healthcare facilities.

Capacity of the public healthcare facilities is affected negatively due to increased workload, high mortality among patients, shortage of staff and working with difficult patients.

Public hospitals struggle to fill existing medical posts complicated by a decrease in enrolment of nurses in state owned health institutions.

Concept of waste avoidance and minimisation has not been institutionalised in public healthcare facilities

Absenteeism and late coming remain serious issues, a major cause of staff shortages and staff burnouts.

Most public healthcare doctors and nurses invariably share their work schedules with the private hospitals

Assign responsibilities across government healthcare levels to fill the gap of resources to ensure effective decision-making.

A staff profile is to be drawn up. Check the national staffing norms and adjust accordingly.

Periodic assessment of practice performance of the frontline health professionals may be a promising step to take where other efforts have had limited success.

Public healthcare staff needs an improved working conditions to match their performance with those of private sectors standards.

Ensure continuous staff motivation and retention as a priority and encourage a team-coaching approach to building staff improvement capabilities.

Efficiency concerns need to be built into resource allocation policies.

Design the systems to recognize improvement and adjust budgets accordingly.

Introduce risk and efficiency management

short training courses

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for nurses and doctors in ensuring avoidance of waste.

Continuous engagement of the healthcare providers in health management decisions is essential as this plays critical roles by virtue of their decision and position as they continue to control the vast majority of healthcare resources.

Objective 4

To indicate how governance / Leadership influence healthcare service delivery

Appointment based on political status quo led to poor decision making.

Non-coherent procurement processes are evident, which escalates service cost.

Staff empowerment through in-service trainings is available, but the enabling environments and conditions of service for the existing ones are inadequate.

The managerial incapability to match service with demand, created such problems as frequent unavailability of essential medications.

At the top-level positions, professional appointments within the discipline must be respected rather than through a political status quo.

Leaders should engage in a process of continuous learning to support transformational change in the pursuit of efficient service delivery.

It is important to carry out precise management reviews for all the core hospital and clinic functions in matching staff and other resources to the demands.

Leadership must internalise monthly evaluations and plotting of the patient-staff ratio, utilising the information systems to make such calculations,

adjustments and demands in meeting needs and trends.

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Objective 5

To show how the implementation and usage of health policies and strategies influences service delivery

Regrettably, the implementation of several policies and strategies either have not been correctly followed due to inadequate process and procedures or are marred by unavailability of an integrated information system and incorrect or non-use of recent innovative ideas.

Pronounced abuse of resources exist in public healthcare facilities by young mothers and asylum seekers on free healthcare services, especially in pregnancy termination, poverty alleviation scheme and pregnancy free services.

Non decentralisation and salary guidelines policies are great concerns

No discernible operating standard and proactive strategies and safety rules are enforced.

Reinforce priority settings by the use of health technology assessments.

Use activity based payment to erase regulations on hospital staffing and equipment to improve the system’s ability to respond to demand and improve efficiency.

Real improvements will come in considering of the way healthcare is paid for.

Full implementation of National Health Insurance is necessary to consolidate under resourced and over-strained healthcare sectors and to increase the weak purchasing power of patients and health facilities alike, ensuring minimal use of resources, and use of technology, right of access to quality care and affordability to all using the facility.

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Objective 6

Service Gaps between Public and Private Healthcare Service Sectors

The vulnerable citizens and low-income earners predominantly use public healthcare sectors.

Excessive hospital lengths of stay abound in public hospitals.

Health Outcomes is low in public hospitals and clinics relative to private.

Absenteeism, late coming and staff shortages in public hospitals are common, resulting in long patient waiting times and medication collection, delays and sometimes, medical errors.

Public hospitals in extremely critical cases demand for private healthcare services, when over stretched by population surge and burden of diseases.

Good number of inexperienced / intern nurses and doctors are found in public healthcare service sectors

The private hospital operates at its optimal size while the public hospitals are not operating at their most productive size for the observed input mix in this study.

High patient dissatisfaction rate of 76% exist in public healthcare facilities relative to 8% in private.

Privatisation is recommended as the final remedy to this crisis based on the excellent performance of the private hospital relative to public hospitals and clinic used in this research, as it will save resources, eliminate waste, reduce debt and above all will create better healthcare and service satisfaction to those who need it.


6.3 Recommendations for Further Research

Conduct efficiency studies among all Gauteng health clinics and all levels ofhospitals to ascertain the extent of this waste crisis and resource ineffectiveness.

Healthcare delivery requires an integrated approach in ensuring optimalperformance and efficiency. This iterative and interactive process involving people and technology is a lifecycle approach that achieves a realizable service delivery; directing research studies towards this end in tailoring of the

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processes aimed at the satisfaction of patients and other stakeholders’ requirements may tilt the balance of inefficiency.

6.4 Conclusion

The public healthcare delivery system without a doubt has not achieved the kind ofefficiencies found in private hospitals. Improving efficiency from one perspective may reduce it from another area, which compromises the overall efficiency.

Improving efficiency to cross the chasm of this quality discrepancy requires transformational changes involving leadership, policies, innovations and models of care in the health system. There should be an application of ‘lean thinking’ principles, practices and tools to enhance delivery and to create value with minimal waste, minimal cost and the shortest possible patient waiting times but with a total mission assurance to patients.

An organized whole-system perspective is fundamental to progress and to meeting the expectations of all the stakeholders. The reorientation of the system must include the funding of the system, remunerations of service providers, ownership of healthcare delivery organisations, system accountability and models of care.

Dimension of quality issues such as accessibility and equity are system dependant that improve through a thorough reformation of the broader system. Decision makers while developing and implementing new strategies, must consider proper engagement of health service providers, communities and service users.

Despite the claims that private hospital service costs are exorbitant, the utilisation of quality of care and service satisfaction is never compromised. Every effort is taken to eliminate any waste of resources, without compromising patient satisfaction and emancipation of gains for the stakeholders.

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Appendices

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Appendix A: Consent form for Research Respondents

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Appendix B: Research Questionnaire

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