Profiling South Africa’s Hospital Landscape
South Africa’s health outcomes are disappointing for a higher middle-income country with our level of development and public spending on health. South Africa’s health outcomes frequently rank lower than those of its much poorer neighbours. The quality of secondary care has a large impact on a range of health outcomes. Due to its prominence on both the local and global public health agenda, maternal mortality provides an interesting clinical case study to demonstrate the impact of hospital performance. Despite being a higher middle-income country, South Africa ranks amongst the forty countries in the world with the highest rates of maternal deaths. While burden of disease (specifically HIV) and demand side factors such as late access to care contribute to the high mortality rates, a recent audit report concludes that hospital performance and the quality of clinical care play a significant and increasingly important role in explaining maternal deaths. The report finds a 25% increase in deaths due obstetric haemorrhage compared to the earlier assessment period and identifies poor clinical assessment, delays in referral, not following standard protocols and not responding to abnormalities in monitoring of patients as the most common avoidable hospital-related factors.
While maternal mortality makes a compelling case for the importance of hospitals for health outcomes in South Africa, the relationship has been shown to hold across a number of clinical areas. A series of quality-of-care audits in hospitals with high and increasing levels of perinatal deaths identified a number of hospital-related factors contributing to the deaths including the lack of antenatal steroids (which speaks to pharmaceutical stock management), insufficient nursing staff, fetal distress not being monitored and in cases where the fetus was monitored, poor progress in labour with incorrect interpretation of the partogram (6). A recent review of patient files in three Cape Town hospitals showed that the door-to-needle time for administration of fibrinolytics for acute myocardial infarction was within the 30 minute benchmark in less than one fifth of cases. Such delays could cost lives and in the cases under consideration the researchers identified a number of avoidable factors such as a shortage of senior doctors, difficulties with interpreting electrocardiograms and emergency centre delays.
While the primary care sector has in past years received more research and policy attention because of greater recognition of the importance of preventative care and the early identification of disease, it is important to highlight that the hospital sector remains responsible for the bulk of healthcare delivery expenditure and therefore it is vital to better understand correlates of health outcomes at the secondary care level.
A network of collaborators including representatives from the Office of Health Standards Compliance, Insight Actuaries, Imperial College London, COHSASA and RESEP health group have formed a network to conduct analysis to describe the South African hospital landscape and better understand the correlates of quality.
Collaborators: Katharina Hauck, Shivani Rancchod, Jacqui Stewart, Cheryl Adams, Julian Bloch, Chloe van Billion