Time to bridge the public/private health divide

There’s no questioning the enormity of what needs to happen before universal health coverage begins to deliver on South Africa’s constitutional imperative (the progressive realisation of health rights for all). The arguments of detractors of our proposed NHI are beguiling. But there’s a new spirit abroad in South African healthcare which begins with a blunt and unapologetic admission that things have got so bad that radical, deeply pragmatic change is way overdue. It shows in the way the national health department, led by its minister, Dr Aaron Motsoaledi, is assessing and revealing dysfunctionality at every level in the system (private and public), carefully amassing data and listening attentively to how it’s being interpreted by some of the world’s top health system experts. As National Director-General, Malebona Matsoso, tells Izindaba’s Chris Bateman,1 ‘We have to do this thing right. If we mess it up, we mess it up forever.’ When we deal with key health officials, the overall impression is of deep commitment, caution and an urgency to consult. One deep reservation though; our leaders have the resolve, but is there enough human capital in the department to make it translate? Time for the private sector to (diplomatically) step up.

Blanket laboratory screening of patients presenting with a mental disorder is wasteful and unnecessary

Crede, Geduld and Wallis2 reviewed the records of all patients presenting to the emergency centre at J G Jooste Hospital, Cape Town, with acute-onset psychotic symptoms over a 6-month period to assess the usefulness of routine laboratory tests in eventual clinical management. Altogether, 2 287 tests were conducted on 604 patients, yielding a paltry 4.5% of abnormal results. In only 2 of the 604 patients screened did the abnormal results change the management of the psychotic patient, suggesting that the tests were redundant and conducted without a clinical indication. The authors conclude: ‘Our findings clearly show that in most cases routine screening tests provide no information additional to that obtained on history and physical examination ... To limit the burden on public health care resources, clinicians should have confidence in their clinical expertise and use blood tests only to corroborate the clinical suspicion of an underlying disorder.’

An audit tool to identify gaps and promote improvement in TB/HIV/STI care in rural districts

Despite an increase in expenditure on infrastructure and human resources for primary level services in South Africa, health services have remained largely ineffective in reducing the caseload and incidence of TB, HIV and STIs, according to Loveday et al.3 The authors describe a service evaluation tool to assess and support these services at primary care level in a rural district, and provide the results of such an audit in which the relevance and usefulness of the tool were tested.

Remote rural communities and health facilities suffer from poverty-related deprivations, limited access to piped water, impassable roads in the rainy season, and limited communication networks, with clinics having little or no communication with the district hospital or offices for weeks. The audit was a participatory quality improvement intervention aimed at assessing performance, setting targets and developing plans to address the problems identified in respect of accessibility, availability, capacity, continuity and quality of care, and integration. Numerous problems were identified including inadequate staff training, drug shortages, unduly long turnaround times for laboratory results, and problems of staff recruitment and attrition. The question arises whether such an audit will eventually contribute to concrete service improvements. It is hoped that the authors will plan for a follow-up impact evaluation.

Medical officers without formal anaesthetic training can safely administer procedural sedation and analgesia

Wenzel-Smith and Schweitzer4 conducted an investigation to assess the safety and efficacy of procedural sedation and analgesia (PSA) administered by medical officers without formal anaesthetic training at a district hospital with 75 beds and 2 theatres. The hospital had no PSA service prior to the study. One of the authors attended a 2-year university course in PSA, and subsequently provided in-house training to interested medical and nursing staff. A PSA service was then established, and the authors documented performance and outcomes of the service. The overall adverse effect rate was low, and no patient required PSA-related admission. Adverse effects, such as they were, clustered around the median age of 40, and were associated with multidrug regimens and the addition of propofol. PSA for children was generally more conservative. The authors conclude that PSA can effectively and safely be administered by appropriately in-house-trained medical officers.

Malaria risk – be warned!

The containment of malaria in South Africa must rate as one of the country’s most dramatic success stories in the health sector, thanks in large part to sensible strategies and unrelenting efforts of the Department of Health and practitioners at the coalface that have seen notified cases reduce by 88% and malaria-related deaths by 81% over the past decade. Nevertheless, Moonasar et al.5 remind us that malaria remains a real and present threat in South Africa, not least because of increasing migration of people to and from malaria-endemic regions. This is malaria season (September to May), and the article highlights the imperative to report malaria cases that may occur in non-endemic regions of South Africa. In the event of infection, early diagnosis and treatment are critical, and a high index of suspicion is essential when confronted with unexplained febrile illness. Avoiding mosquito bites is the bedrock of prevention, achieved by using approved skin repellents and taking environmental precautions such as staying indoors in rooms with screened doors and windows. The article lists currently approved chemotherapeutic prophylactic agents.

DJN

1. Bateman C. ‘Wing and a prayer’ days over for SA’s healthcare system. S Afr Med J 2011;101:859-861.

2. Crede A, Geduld H, Wallis L. Assessment of routine laboratory screening of adult psychiatric patients presenting to an emergency centre in Cape Town. S Afr Med J 2011;101:891-894.

3. Loveday M, Scott V, McLoughlin J, Amien F, Zweigenthal V. Assessing care for patients with TB/HIV/STI infections in a rural district in KwaZulu-Natal. S Afr Med J 2011;101:887-890.

4. Wenzel-Smith G, Schweitzer B. Safety and efficacy of procedural sedation and analgesia (PSA) conducted by medical officers in a level 1 hospital in Cape Town. S Afr Med J 2011;101:895-898.

5. Moonasar D, Asomugha C, Baker L, et al. Preventing disease and saving lives: The malaria season is upon us. S Afr Med J 2011;101:865-867.