Opinion, South Africa

The Final Say: Prof Househam Talks about the State of Healthcare

Prof Craig Househam talks about his time leading the WC DoH, the importance of eHealth in the public sector and the future of healthcare in South Africa.

Prof Househam - EHN

In the run up to Professor Craig Househam stepping  down as Head of the Western Cape Department of Health (WC DoH), he talks to eHealthNews about his time leading the WC DoH, the importance of eHealth in the public sector and the future of healthcare in South Africa.

What was the most pressing issue you were facing when you took over in 2002 and what has been achieved since?

When I took over as Head of the WC DoH, it was struggling to function within its budget and my first brief from the then-premier was to stabilise the Department’s finances. I became quite unpopular with some people at that point who accused me of “putting cash before care” but we succeeded in becoming financially stable. Testimony to that is the fact that we’ve had an unqualified audit and remained within budget for the last ten years; something no other health department in the country has achieved.

As a result of stabilising the finances, we were able to stabilise the healthcare service in the Western Cape. Added to that we have good managerial structures, good doctors and clinicians, more specialists per capita than any other province and we are the employer of choice for junior doctors applying to complete their internships and community service.

We also developed and implemented the Healthcare 2010 strategy and I believe that to a large extent we have achieved the restructuring that was set out in the document. As a result, we offer reasonable access to healthcare in the province within the constraints of a rapidly increasing population and a growing burden of disease.

Some people would argue that the Western Cape has always had an advantage over other provinces in terms of managerial capacity and staffing, but after 20 years I think one has to accept that things should have come further than they have and it’s something that we’re grappling with in this country.

What is the next phase of the Department’s growth?

Healthcare 2010 focused on addressing the structural and affordability issues around delivering healthcare. We’re building on that in Healthcare 2030, another forward thinking strategy that we’ve developed over the last two years. While I think we deliver a good and reasonable health service, we still have the question of quality to address and that is where we are most vulnerable. Healthcare 2030 focuses much more on what we’ve envisioned for healthcare in the Western Cape – a people-centred, quality service.

And what does that mean?

A people-centred health service is where both the patient and the healthcare workers are the focus and as a result of that prioritisation, you get a quality health service. It’s the kind of health service that anybody, be it a paying patient or non-paying patient, one with medical aid or not, would be comfortable to go to. To a large degree, a lot of people who have medical aid would feel very uncomfortable if they were told they had to go to a state hospital. Our challenge is to provide a service where you feel good and at ease using public facilities. In the process towards NHI or essentially, universal healthcare for everybody, the state must provide a quality service that everybody is prepared to go to and that’s where we are headed next.

What are the first steps in realising quality healthcare?

Our first step is to address the burden of disease. As a country, we need to curb the increasing number of people presenting themselves to our health services. Developments in health technology have made more and more possible but healthcare costs money and the more we can do, the more people expect. So while the healthcare budget could be infinite in its needs, our resources are limited and we can’t afford the rising cost of healthcare. We have to reduce the burden of disease and get people to accept responsibility for their own health and wellness.

Currently, what burdens the system is people presenting to the health service for reasons that could have been prevented. We need to shift our focus to keeping people healthy rather than treating people who are ill. This concept of preventative care is our biggest challenge and it means changing behaviours that result in obesity, heart disease, hypertension, diabetes, smoking-related cancers, alcohol-related accidents and violence, etc.

Changing human behaviour is much more difficult than writing out a prescription or giving someone a pill or an injection.  We are not unlike the rest of the world in grappling with the burden of disease but, the disease spectrum in Africa and South Africa being what it is, instead of just facing a disease burden of non-communicable diseases or chronic disease we also have a disease burden caused by infectious disease and preventable diseases due to trauma, road accidents and violence. It’s true that doctors from developed countries come to work in our hospitals because they see more trauma cases over the weekend in the Cape Metro than they do working in a war zone. But if we take away the burden of infectious disease and preventable disease, we’ll have reduced the load on our health services by probably 50 – 60% and we’re left with many more resources for other things – health services and beyond.

What impact do you think eHealth will have on improving service delivery and patient outcomes?

The use of technology in healthcare has immense potential on a number of levels. Developments in smartphones, the Internet of Things and wearable technology are starting to be used as tremendous tools for preserving wellness. It can be used to record your vitals, by a doctor to monitor your health, it can even be used to teach and engage you in wellness programmes. But the question then becomes: what is the incentive to use it?

Technology provides greater and faster access to information, but is it going to influence an individual’s lifestyle? Discovery and other big players in the sector have pioneered programmes that incentivise their members to do today what’s valuable for their health in the long term. At the Health Department we’re looking at what incentive we can offer the general public. For instance, could we potentially guarantee shorter waiting times at clinics if you adhere to certain programmes – potentially delivered on an eHealth platform, or could we offer a discount on your hospital fee? So, in terms of eHealth’s potential to benefit the individual’s health, we are currently looking at how to enable its potential for the Western Cape population.

As far as how eHealth can improve the efficiency of the health system, there are major benefits to implementing things like electronic prescribing, Electronic Patient Records (EPRs), electronic dispensing, etc. In some ways, we are stifled by what is required by legislation and what can be done by technology. For instance, our systems currently do not accept electronic signatures and therefore we can’t use eprescribing without an accompanying paper prescription. But if we could, it would be very advantageous for us. Our Central Dispensing Unit (CDU) manually packages 200,000 parcels a month and we could drastically reduce the human error associated with capturing a paper-based prescription onto an IT system that then processes and dispenses with eprescribing anyway.

EPRs is another solution to a growing problem we face at a number of our facilities. At the moment we have 12.5 million patient files for a Western Cape population of around 6 million people. By law we are obliged to store the paper files of a child until they are 21 years’ old and an adult’s folder until such time that it has not been used for five years. But the reality is that we’re being forced out of our facilities by vast numbers of paper files. We’re in the process of converting to an electronic content management system in three of our hospitals however, the Auditor General and Archiving Act still requires us to retain the paper on which that system is based. At some point we will need to move to paperless systems entirely and there is tremendous potential for accurate, up-to-date record keeping with digital solutions.

We’re also investigating an exciting tablet-based clinical decision support tool that would allow doctors to capture patient notes in a manner most familiar to them while the system maps and checks the new note against the patient’s history to flag any potential warnings, and suggest possible diagnoses and treatment.  A system like that would make it possible to keep problem and medication lists updated, automatically schedule follow-up visits and potentially make the record available for the patient to see too. Similar systems have been introduced in US hospitals and we believe there’s potential for a robust clinical decision support tool here too.

Those are just some examples of the tremendous potential of eHealth on various levels: altering patient behaviour, improving patient adherence, more efficient treatment protocols, and better management of patients, better follow-up, and more effective distribution and delivery of medicine. They must all however, have a cost benefit; so what the system costs us, it must save us in the end.

What do you think other DoH Heads need to prioritise to meet or exceed the progress that’s been made in the Western Cape?

The National Minister, Dr Aaron Motsoaledi, for whom I have the greatest respect for what he has done for this country particularly with regards to correcting the government’s previous AIDS policy, asked me a similar question and my response was and is that you have to get the basics right. Fundamental to making any progress is to manage resources appropriately. It sounds obvious but good financial management is something that many health departments are struggling with. Patients always justify the need to spend but resources are limited so if you’re allocated funds, make sure every Rand is used for what it was allocated for.

Secondly, if you’re going to spend money, don’t waste it by spending on things or people you don’t need. I don’t believe you should employ people that you can’t gainfully utilise. If you haven’t got the money to provide them with the tools they need to do their job, don’t employ them. The WC DoH has what’s called an “approved post list” which defines the number of posts we can afford and is revised on an annual basis according to the available budget. Within that number any manager can appoint or replace staff without getting prior approval from higher management. If they want to exceed that number, they have to explain to myself and the CFO where the money will come from to pay that person. If they are going to convert some of the goods and services budget into a salary, they need to prove that there is enough medicine, oxygen, dressings, theatres, etc. so that the person they are employing will have everything they need to do their job. There have been a number of instances whereby staff haven’t had what they need and as a result salaries have been wasted and personnel underutilised and dissatisfied with working conditions.

Once the financial management and HR is sound, infrastructure is the next priority. When I arrived at the Department, we were cutting on the maintenance budget and equipment budget. I was shown first-hand the effects of this during a visit to Groote Schuur Hospital which was struggling to function with outdated aesthetic machines.  We had to buy equipment in such a way that we could offer a reliable service and get the best value for money. The equipment may not always be the most modern but it works.

Basics like these are not ensured in a lot of provinces, which highlights the necessity for effective management and adherence to discipline because that is what makes a big organisation like this work. Yes, we are clumsy at times and yes, we are a bureaucracy, but managers – including myself – must be held accountable.

A lot of departments think that sitting in meetings, writing documents and talking about it solves problems. It doesn’t. In my view, committees never get things done. They don’t make decisions, individuals take decisions. Empower your managers to make decisions and take responsibility for them. And of course, it’s important to support them if they make a mistake. I think there is an intolerance of incompetence but I think there’s a greater intolerance of people who just don’t care. What health managers do is life and death for some people so if we make a mistake or do things badly, people suffer. I’m not a practicing doctor anymore but I spent 20 years in clinical practice and I have the same attitude to running a health department as I did when treating a single patient in that if I do something wrong, somebody is going to suffer, and I like my whole team to have the same view.

So my advice to my fellow heads of department and managers is that healthcare is not a complex business when you reduce it to its simplicity. Get the basics right, look for the simple in the complex – it’s there if you look for it. You can get lost in the complex. But that’s probably a complex answer to a simple question.

In terms of management issues we face in South Africa, do you think you must be a clinician to be a health manager?  

I don’t think you have to be a health professional to be a health manager, but it helps. Health management is a specialty on its own and because you are a good doctor or nurse, does not necessarily mean you will be a good manager, although it is often the case.

A lot of the health management in this country has tended to focus on strategic planning, leadership and vision but it needs to be a lot more substantial in terms of the basic requirement. You’ve got to understand the finances, HR, logistics, procurement and supplies for example. It’s a wide ranging field that needs expertise and I agree with Dr Motsoaledi that health management needs to be professionalised and ultimately, you should not be able to manage a health facility without a certified qualification.

South Africa’s health sector has struggled to retain staff. What are the key issues that need to be addressed to build an adequate workforce?

Key to retaining medical staff is improving the working conditions and remuneration. The Occupational Specific Dispensation (OSD) for healthcare has made a lot of progress in providing adequately competitive salaries for doctors. If you look at the comparative salaries of young, mid-level and senior doctors and contextualise it in an African setting, salaries are good. If you work in the UK and convert earnings by the exchange rate, then yes, there is a significant difference but a relatively junior doctor in this country can earn R600,000 – R700,000 a year with overtime. That doesn’t happen in any other sector. It’s true that doctors work hard and conditions are difficult but they are paid well.

So the issue of remuneration is less about what staff are earning and more whether they are actually being paid, on time, every month. It’s a kiss of death to a system when you don’t pay your doctors and nurses and that’s unfortunately been the case in this country at times. It is a disgrace and it should never happen.

As far as the working conditions are concerned, I think on one hand this is the collective responsibility of the health department, the community and broader government. We have had incidents of EMS staff getting robbed when they go into dangerous areas, nurses in uniform being attacked on their way home and a doctor who was hijacked and murdered despite being a known and important member of the community he was serving. We, as the Health Department, need to protect our staff and make sure they are safe within the hospitals or clinics but there are some issues that the community needs to take responsibility for.

We also recognised that retaining staff requires that we give them room to grow. One of the initiatives we’ve started in the Western Cape is Functional Business Units (FBUs). Within a hospital, the doctors create expenditure in the health system because they give instructions that cost money, like ordering an X-ray or blood tests or surgery. FBUs essentially give doctors a budget, staff, the responsibility to provide an agreed amount of service, and a suite of data to be able to measure what they are managing.

I’m encouraged by the number of instances where clinicians are enthusiastic about the initiative and instead of being frustrated with management and the “pen pushers” sitting in Dorp Street; we now have what I would categorise as Clinician Managers. By giving doctors the opportunity to get more involved, make decisions and be held accountable for the outcomes, we’ve uncovered another way of improving working conditions and giving them some control over their destiny.

To healthcare personnel I would say that you can immigrate – a medical qualification from this country means you’re exceptionally mobile – but rather stay here because it is an exciting place to work. It’s got lots of positives; you can serve a community and really make a difference.

What would you say to innovators or tech entrepreneurs wanting to work with government to deliver eHealth solutions?

Most importantly, understand how we do business and that it is different to how the private sector does business. Often innovators or private companies will show us their solution and expect us to buy it immediately, either without an understanding of what our needs are or the process we need to follow as a government organisation. Simply, we release a spec of what we need and all the companies who want to bid for the tender are expected to compete for the sale based on things like price, specifications and BEE status, etc. After an evaluation process, we then grant a contract but that process is sometimes frustrating for the private sector.

For private companies wanting to start engaging with government, our Public Private Health Forum (PPHF) is a good place to get an understanding of what the issues are that we need to address and how their solution might be of value to us.

What advice can you offer your successor?

The advice I can offer is what has worked for me and that is: get the basics right, develop a thick skin, don’t be scared to make the odd mistake, and take genuine but constructive criticism as an opportunity to do your job better. I’ve learnt a lot as a manager from constructive criticism from the inside, outside and those at the coalface. Often the health worker has the solution but management doesn’t listen.  Hearing what people around you are saying is absolutely key to knowing what direction to take.

I am confident that there are people who can do my job and may even do it better than I do. Health management is not a glamorous or exciting business a lot of the time. It is difficult and I expect my successor will do things differently but I am stepping down with the certainty that this department, with the right leadership and effective management, is in a good position to go to the next level which is what 2030 demands…a person-centred quality health service.

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