EDITORIAL

 

Clinician-driven strategies to sustain health justice in the public health sector

 

 

Ntambue Kauta

Mitchell's Plain Hospital, Cape Town; University of Cape Town, Cape Town, South Africa

 

 

 

One objective of the South African National Health Act No. 61 of 2003 is the provision of best possible healthcare services to all within the limits of available resources.¹

Cost consciousness and prevention of wasteful expenditure is required to sustain the provision of a high standard and affordable medical care to all. When available resources are threatened and diminishing, as is the case in our nation in these recent months and likely to persist for the foreseeable future, elective surgeries are at imminent risk of being postponed indefinitely. The tendency to delay or postpone elective surgery emanates from the natural need to prioritise patients with acute life-threatening conditions or traumatic injuries which compete with elective pathologies for resources. Postponement of elective surgeries prolongs patient suffering and poor quality of life, and does not support the mandate of health justice.

Ackerman reported that more than half the patients on an arthroplasty waiting list for an average of six months experienced a decline in their quality of life while waiting for their surgery.² In some cases, as seen in long-standing large joint osteoarthritis, patients develop bone loss and deformities which make the delayed surgery much more complex.

It is, therefore, of paramount importance that clinicians engage in resource preservation strategies wherever possible to ensure we continue to provide elective surgery services despite tight national and provincial health budgets.

As clinicians, we are at the receiving end of the state financial policies, treasury, and supply chain entities. We cannot effect changes at this level of administration. We can however, through clinical governance, engage or create resource preservation strategies and prevent service collapse.

One such strategy is the creation of integrated health platforms. The aim of an integrated service platform is to establish a seamless communication system and interplay between clinicians from the primary healthcare centres, specialists at secondary level hospitals through to the subspecialists at tertiary centres. This integrated service platform has the potential to ensure that each individual patient is seen at the correct level of care, receives only the absolutely indicated investigations and gets the correct surgery done correctly. This approach, on a larger scale, can appropriately limit wasteful expenditure and lower the demand on the health budget, while increasing access to better healthcare for those patients who need it most.

This is possible with the use of telehealth, telemedicine or mobile health technology. Orthopaedic surgery lends itself easily to the use of such technology. High quality images can be safely shared among physicians on different levels of care for diagnostic and management purposes in a streamlined fashion. It has been reported that community service doctors and interns were able to successfully manage 50% of their acute fractures in the community health centres (CHC) with the help from their secondary level specialist orthopaedic team through service integration using mobile health technology.³

A well-integrated service platform allows for an effective upskilling of physicians and surgeons through different levels of care. The University of Cape Town (UCT) and Stellenbosch University (SU) orthopaedic service platforms can be evoked as models to emulate. In the case of UCT, the tertiary hospital has employed consultants to work alongside consultants at secondary level hospitals to increase the specialist workforce at this level. This service boost is extended to the primary level through scheduled outreach clinics in CHCs.

The UCT tertiary orthopaedic department also has an open training option for specialists' upskilling. It allows secondary level specialists to upskill themselves at tertiary level through organised fellowships. Secondary level specialists are often invited to operate at tertiary level when tertiary level specialists are not available. The upskilling of secondary level hospital surgeons allows for certain highly specialised surgeries such as joint replacement and minimally invasive surgery, to be safely offered on the secondary level, thus decompressing waiting lists at tertiary level.⁴

The secondary level department also provides training for the primary level physicians using mobile health⁵ and the two-monthly outreach clinical visits. This approach allows for a specialist-led orthopaedic service at all levels of care. It limits wasteful expenditure and makes resources available to those patients who need it most. Through this interplay, a professional relationship develops among the interacting physicians, grounding the concept of teamwork.

It is true that, even with a flourishing economy, wasteful expenditure through inappropriate investigations, and correct surgery done incorrectly or at the wrong level with resulting complications, will invariably deplete resources. Long-term and sustainable solutions lie in developing integrated service platforms aimed at facilitating communication and skills transfer across all levels of care. Tertiary departments are in the best position to organise and develop such integrated platforms.

Another resource preservation strategy is the creation of additional resources. Additional resources can be mobilised outside the government sphere when one considers organised donations for a specific cause. The Joint Care Trust in the Western Cape is an example of a registered not-for-profit trust through which additional resources are generated to provide hip and knee replacements to state patients in the private sector. The trust is supported by a group of five private surgeons who provide an average of 50 joint replacements per year to state patients at Mediclinic Constantiaberg Hospital at no cost to the state or the patient. Through such structures, implants and capital equipment may be sourced and donated to government hospitals as well.

These resource-preservation strategies are clinician driven. With a sense of creativity, clinicians can find multiple ways to preserve resources and actively participate in the mandate of health justice.

 

References

1. The National Health Act No 61 of 2003.         [ Links ]

2. Ackerman IN, Bennell KL, Osborne RH. Declinein health-related quality of life reported by more than half of those waiting forjoint replacement surgery: a prospective cohort study. BMC Musculoskelet Disord. 2011;12:108-108. https://doi.org/10.1186/1471-2474-12-108        [ Links ]

3. Kauta NJ, Groenewald J, Arnolds D, et al. WhatsApp mobile health platform to support fracture management by non-specialists in South Africa. Am Coll Surg. 2020 Jan;230(1):37-42.         [ Links ]

4. Laubscher K, Dey R, Nortje M, Held M, Kauta N. Primary hip and knee arthroplasty at district level is safe and may reduce the burden on tertiary care in a low-income setting. BMC Musculoskelet Disord. 2022 Nov 25;23(1):1014. https://doi.org/10.1186/s12891-022-05936-z        [ Links ]

5. Kauta NJ, Swanepoel S, Salence B, et al. A survey on the educational value of an mHealth referral app for orthopaedics in South Africa. SA Orthop J. 2023;22(1):24-27.         [ Links ]

 

 

* Corresponding author: jimmykauta@gmail.com