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Healthcare Service delivery efficiency; performance of gauteng hospitals

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There 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 sub-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 this research.

This research made use of Performance Assessment Tools for quality improvement in Hospitals (PATH) framework and Data Envelopment Analysis (DEA) to evaluate the satisfaction levels, performance and technical efficiencies of public hospitals, which were 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. Patients’ dissatisfaction level was 76%. The efficiency constant returns to scale (CRS) were (40%), (63%) and (100%) respectively for district, regional and private hospitals while their variable returns to scale (VRS) were 60%, 37% and 100% with scale efficiency score of 92%, 52% 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

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Healthcare Service delivery efficiency; performance of gauteng hospitals

  1. 1. 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
  2. 2. Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals 21 October 2013 i Abstract There 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.
  3. 3. Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals 21 October 2013 ii 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.
  4. 4. Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals 21 October 2013 iii Table of Contents Chapter 1: Background to the Research Study ............................................................1 1.1. Introduction...............................................................................................................1 1.2. Rationale of the Research......................................................................................2 1.3. Problem Statement..................................................................................................4 1.4. Importance of the Problem.....................................................................................4 1.5. Research Objectives...............................................................................................4 1.6. Limitations and Assumptions of the Research....................................................5 1.7. Conclusion................................................................................................................5 Chapter 2: Review of Literature.........................................................................................6 2.1. Introduction...............................................................................................................6 2.2 Health Review ..........................................................................................................6 2.2.1 Demographics..................................................................................................6 2.2.2 Gauteng Healthcare Overview ......................................................................8 2.2.3 Health Assessment .........................................................................................9 2.3 Health Strategies Review.....................................................................................12 2.4 Human Resources.................................................................................................15 2.5 Health Expenditure................................................................................................15 2.6 Healthcare Service Performance ........................................................................17 2.7 Healthcare Service Satisfaction ..........................................................................18 2.8 Hospitals Efficiency in Gauteng ..........................................................................19 2.9 Gauteng Public and Private Healthcare Service Overlaps .............................20 2.10 Conclusion..............................................................................................................21 Chapter 3: Conceptual Theories and Performance Models.....................................22 3.1. Introduction.............................................................................................................22 3.2. Healthcare System and Governance Concept .................................................22 3.3. Hospital Levels and Service Structure ...............................................................24 3.3.1. Primary Healthcare (PHC) ...........................................................................24 3.3.2. Hospital ...........................................................................................................26 3.4. Healthcare Technology Innovation Concept .....................................................28 3.4.1. Integration of Health Information Systems ................................................30 3.4.2. Healthcare Innovation Conceptual Framework ........................................31 3.5. Performance Assessment Framework...............................................................33 3.5.1. Outcome Based Performance Assessment Framework .........................33 3.5.2. Performance Assessment Tool for quality improvement in Hospitals Model (PATH)……………………………………………………………….34 3.6. Healthcare Service Delivery Concept ................................................................37 3.6.1. Service Delivery Models...............................................................................40 3.7. Healthcare Efficiency Concept ............................................................................42
  5. 5. Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals 21 October 2013 iv 3.7.1. Related Efficiency Terms .............................................................................44 3.7.2. Application of Data Envelopment Analysis (DEA)....................................45 3.7.3. DEA Limitations .............................................................................................48 3.8. Conclusion..............................................................................................................48 Chapter 4: Research Design and Methodology ..........................................................49 4.1. Introduction.............................................................................................................49 4.2. Qualitative Research.............................................................................................49 4.3. Qualitative Research Methods ............................................................................50 4.4. Advantages of Qualitative Research ..................................................................51 4.5. Basics of the research ..........................................................................................52 4.6. Research Design...................................................................................................52 4.6.1. Research Method ..........................................................................................53 4.6.2. Purpose and conceptual context.................................................................53 4.6.3. Validity.............................................................................................................55 4.7. Conclusion..............................................................................................................56 Chapter 5: Results...............................................................................................................57 5.1. Introduction.............................................................................................................57 5.2. Demographics Data...............................................................................................57 5.3. Service Indicators ..................................................................................................59 5.3.1. Nature of Service and Patient centeredness (Satisfaction) ....................59 5.3.2. Service Availability and Resource Allocation ............................................60 5.3.3. Facility Capacity and Service Utilisation ....................................................61 5.3.4. Information Systems and Technology Innovation ....................................63 5.3.5. Governance (Leadership) ............................................................................65 5.3.6. Government Policies and Strategies ..........................................................66 5.3.7. Health Outcomes...........................................................................................67 5.4. Result Analysis.......................................................................................................68 5.4.1. Service Gaps between Public and Private Healthcare Sectors .............71 5.5. Conclusion..............................................................................................................72 Chapter 6: Conclusions and Recommendations........................................................73 6.1. Introduction.............................................................................................................73 6.2. Performance Recommendations ........................................................................73 6.3. Recommendations for Further Research ..........................................................78 6.4. Conclusion..............................................................................................................79 References............................................................................................................................80 Appendices...........................................................................................................................89
  6. 6. Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals 21 October 2013 v List of Figures Figure 2.1: Gauteng Provincial Health Services Structure ...............................................8 Figure 2.2: Trends in South African Mortality....................................................................11 Figure3.1: Concept of Health System and Public Health Boundaries ..........................23 Figure 3.2: Health Monitoring Committees ........................................................................23 Figure 3.3: South African Health Delivery System...........................................................25 Figure 3.4: Types of Healthcare Innovation ......................................................................29 Figure 3.5: Health Information Exchange ..........................................................................30 Figure 3.6 How increasing value increases information intensity.................................31 Figure 3.7: Healthcare Innovation Framework..................................................................32 Figure 3.8: A Win-Win Innovative Transformation ...........................................................32 Figure 3.9: Performance Framework Showing the Health Outcomes ..........................34 Figure 3.10: PATH Conceptual Model ...............................................................................35 Figure 3.11: Performance and Quality Measures (Triad Interactions)..........................36 Figure 3.12: Determinants of Performance .......................................................................37 Figure 3.13: Systematic View of Service Delivery............................................................38 Figure 3.14: Changing Value Dimensions.........................................................................39 Figure3.15: Citizen Health Decision Approach................................................................39 Figure 3.16: Six Domains of Performance Interventions ................................................42 Figure 3.17: Topology and Types of Efficiency ................................................................43 Figure 3.18: Determination of Hospital Efficiency Using DEA Analysis........................46 Figure 3.19: Hypothetical Illustration of Technical Efficiency .........................................47 Figure 4.1: Research Methods............................................................................................49 Figure 4.2: Qualitative Research Methods........................................................................50 Figure 4.3: Interactive Model of Research Design...........................................................52 Figure 5.1: Production Possibility Frontiers indicating the Efficiency Trend Using the Input/Output mix of the Hospitals........................................................................................70
  7. 7. Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals 21 October 2013 vi List of Tables Table 2.1: Gauteng Public Hospitals / Levels .....................................................................7 Table 2.2: Demographic Indicators of Gauteng Province (Extract) .................................8 Table 2.3: Past 15 years Accomplishments and Shortcomings of South African Health ........................................................................................................................................9 Table 2.4 South African Health Review for First Quarter 2011......................................10 Table 2.5 Provincial Health Expenditure (Rands in millions)..........................................16 Table 3.1: Stakeholders Needs, Wants and expectations ..............................................28 Table 3.2: Key Hospital Performance Dimensions ..........................................................35 Table 3.3: Evolution of Service Delivery Models .............................................................40 Table 3.4: Service Delivery Models with Improved Competencies ...............................41 Table 3.5: DEA Analysis using a hypothetical illustration ...............................................47 Table 5.1: Hospital Variables...............................................................................................69 Table 5.2: Efficiency Ratios of the Hospitals.....................................................................70 Table 6.1: Performance Recommendations ....................................................................73
  8. 8. Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals 21 October 2013 vii 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
  9. 9. Chapter 1: Background to the research study 21 October 2013 1 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
  10. 10. Chapter 1: Background to the research study 21 October 2013 2 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
  11. 11. Chapter 1: Background to the research study 21 October 2013 3 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.
  12. 12. Chapter 1: Background to the research study 21 October 2013 4 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 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.
  13. 13. Chapter 1: Background to the research study 21 October 2013 5 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.
  14. 14. Chapter 2: Review of Literature 21 October 2013 6 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
  15. 15. Chapter 2: Review of Literature 21 October 2013 7 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.
  16. 16. Chapter 2: Review of Literature 21 October 2013 8 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.
  17. 17. Chapter 2: Review of Literature 21 October 2013 9 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
  18. 18. Chapter 2: Review of Literature 21 October 2013 10 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)
  19. 19. Chapter 2: Review of Literature 21 October 2013 11 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/AIDS TB/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
  20. 20. Chapter 2: Review of Literature 21 October 2013 12 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
  21. 21. Chapter 2: Review of Literature 21 October 2013 13 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 countering access 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 in the 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
  22. 22. Chapter 2: Review of Literature 21 October 2013 14 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 in 2003, 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 the inadequacies in human resources, governance, burden of diseases, and excessive
  23. 23. Chapter 2: Review of Literature 21 October 2013 15 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, a country 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
  24. 24. Chapter 2: Review of Literature 21 October 2013 16 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 more per 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 Support Team,” reviewed health overspending and macro-assessment of public systems in South Africa. After an extensive investigation, it came up with a report that “bloated”
  25. 25. Chapter 2: Review of Literature 21 October 2013 17 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 Africa ranks 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,
  26. 26. Chapter 2: Review of Literature 21 October 2013 18 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 grossly inadequate, 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 public healthcare facilities:
  27. 27. Chapter 2: Review of Literature 21 October 2013 19 “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 avoid error 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
  28. 28. Chapter 2: Review of Literature 21 October 2013 20 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.
  29. 29. Chapter 2: Review of Literature 21 October 2013 21 2.10 Conclusion The burden of diseases, limited available resources, changing policies, incoherent information 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 the increased 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.
  30. 30. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 22 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 regulation of pharmaceuticals is at the centre stage of meeting the patient’s healthcare service
  31. 31. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 23 expectations (Department of Health, 2005:3). Figure 3.1: 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 3.2: Health Monitoring Committees Source: Gauteng Department of Health, 2003:5.
  32. 32. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 24 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).
  33. 33. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 25 Figure 3.3: South African Healthcare Delivery System Source: WHO, 2006:8-6.
  34. 34. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 26 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 Hospital According 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 Hospital Ngwenya (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:
  35. 35. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 27  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).
  36. 36. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 28 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 3.1: Stakeholders Needs, Wants and expectations Source: Omachonu and Einspruch, 2010:9.
  37. 37. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 29 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 3.4: 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
  38. 38. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 30 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 3.5: 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).
  39. 39. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 31 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 3.6 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 five major 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).
  40. 40. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 32 Figure 3.7: 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 3.8: A Win-Win Innovative Transformation Source: Adams et al., 2008:23.
  41. 41. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 33 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) and public, 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).
  42. 42. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 34 Figure 3.9: 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).
  43. 43. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 35 Figure 3.10: 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 3.2: Key Hospital Performance Dimensions Source: WHO, 2007:6.
  44. 44. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 36 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 3.11: 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).
  45. 45. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 37 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 3.12: 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 not necessarily, 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
  46. 46. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 38 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 models for 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 3.13: 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.
  47. 47. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 39 Figure 3.14: Changing Value Dimensions Source: Adams et al., 2008:4. Undoubtedly, the health financial burden is heavy on government with a shift to individuals (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. Figure3.15: Citizens Health Decision Approach Source: Adams et al., 2008:7. High value care demands the participation of patients in the health decision-making process 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,
  48. 48. Chapter 3: Conceptual Theories and Performance Models 21 October 2013 40 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 3.3: Evolution of Service Delivery Models Source: Adams et al., 2008:17. Community health networks ensure access optimization across a defined geographic area while centre of excellence optimizes clinical quality and specific medical conditions. Medical concierge (special service) focuses on optimization of the 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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