EDITOR'S CHOICE

Quo vadis health care quality assurance?

Public debate rages over the implications of the much-needed National Health Insurance system, but often overlooked is the architecture of the current quality assurance groundwork for health care facilities. The NHI's ability to deliver anything of real value will be built on this foundation.

Chris Bateman takes a look at the 3-year-old Office of Standards Compliance (OSC), responsible for creating minimum health care standards in both public and private sector facilities, the former in desperate need of improvement through competent evaluation, rating and monitoring.¹ His investigation uncovers fall-out between the OSC and the leading local NGO in the field, the relatively veteran Council for Health Service Accreditation of Southern Africa, COHSASA.

Is the OSC clumsily 'reinventing the wheel' as claimed (COHSASA has accredited 55 public and 25 private sector local hospitals in a process begun a decade before the OSC existed), or is a more nuanced national model appropriate? Is the split between the two cause for concern, or is reconciliation possible and in the interests of us all?

The spat gives unique insight into the work done so far and raises concerns over how effective the methodology and instruments devised will be. Only time will tell.

Mental health requires advocacy

It is estimated that 14% of the global burden of disease is attributable to neuropsychiatric disorders, with depressive illness, anxiety disorders, substance abuse and psychotic disorders contributing the greatest proportion. Neuropsychiatric disorders rank third in the contribution to burden of disease in South Africa. Co-morbidity with physical illness and substance abuse is common. Individuals with mental disorders are at substantially higher risk of cardiovascular disease, diabetes and reduced life expectancy. Two papers^2,3 report on studies of mental health services in KwaZulu-Natal, and an editorial⁴ pleads for advocacy through activism to address serious shortcomings in these services.

Burns⁴ notes that since 1994 the South African government has worked hard to create legislation and policy that place equality, human rights and justice at the centre. However, it is depressing that in many (if not most) cases those charged with implementing the transformative changes in society have failed. Lack of skills coupled with unwillingness to consult with workers at the coalface has resulted in poor planning, inappropriate interventions and wasted resources. The papers^2,3 provide data from KwaZulu-Natal substantiating claims that in that province good legislation has not translated into good practice as far as provision of psychiatric services is concerned. The Mental Health Care Act (2002) provided progressive changes including the introduction of the 72-hour observation period at designated hospitals and the appointment of Mental Health Review Boards. However, the mental services are characterised by inequitable funding and resource allocation, shortages of mental health facilities and professionals, minimal tertiary psychiatric services and lack of proper planning, provisioning, training and support at general hospitals to enable them to perform their mandated functions.

The HIV/AIDS advocacy movement had remarkable success in changing the reluctance of the South African government to face up to the pandemic and to commence treatment. Drawing on their lessons, Jonathan Burns proposes similar action to transform mental health services in South Africa. Firstly, any successful advocacy group must be represented and driven by 'user activists' - that is individuals living with HIV, mental illness, etc. Secondly, highly successful campaigns have recruited champions to help raise their causes, e.g. Bono of the Irish superstar band. Thirdly, good evidence is required. Burns notes that sitting and waiting for the government to experience a spontaneous change of heart will lead to nothing.

Rethinking home testing for HIV

The public has been warned against using HIV self-testing kits by the South African Medical Association and members of the national Department of Health. Marlise Richter, Francois Venter and Andy Gray⁵ argue cogently why this view should be changed.

Self-tests for HIV in South Africa are currently unregulated. Gaps in law and policy have created a legal loophole where such tests could effectively be sold in supermarkets, but not in pharmacies. South Africa lacks an effective regulating mechanism for diagnostic tests, which brings the quality and reliability of all self-tests into question. Although HIV self-tests should fall under the definition of a 'medical device', no mechanism for the registration of medical devices currently exists.

Opposition to self-testing has relied heavily on the claim that self-tests could be inaccurate and should therefore not be available to the public. Such arguments are largely based on vague fears with little or no evidence to support them.

The authors argue that the availability of accurate home-based tests will increase access to HIV testing, especially for individuals who have fears about stigma and confidentiality when testing in public facilities, will remove some of the burden of the 'worried well' from the public and private health system, and will encourage regular testing within the general population. Individuals should be able to decide when and where they would like to test for HIV, and do so without having to involve anyone else.

JPvN

1. Bateman C. Quo vadis health care quality assurance? S Afr Med J 2010;100:620-623.         [ Links ]

2. Ramlall S, Chipps J, Mars M. Impact of the South African Mental Health Care Act No. 17 of 2002 on regional and district hospitals designated for mental health care in KwaZulu-Natal. S Afr Med J 2010;100:667-670.         [ Links ]

3. Burns JK. Mental Health Services funding and development in KwaZulu-Natal: A tale of inequity and neglect. S Afr Med J 2010;100:662-666.         [ Links ]

4. Burns JK. Mental health advocacy - lessons learned from HIV activism. S Afr Med J 2010;100:654-656.         [ Links ]

5. Richter M, Venter WDF, Gray A. Home testing for HIV: AIDS exceptionalism gone wrong. S Afr Med J 2010;100:636-642.         [ Links ]