Debates, critique and commentary on the National Health Insurance (NHI) Bill may be part of the process of reaching universal health coverage, but some solutions to deliver better care for more people sooner may be in lying in plain sight.
For Professor Jannie Hugo, head of the University of Pretoria’s family medicine department (UP-DFM) , moving the NHI debate forward must include optimising the co-ordination of patient care through integrated community-oriented primary care. It’s the one crucial element of universal healthcare that he says can, without significant additional costs, yield better results within the constraints of a healthcare system under extreme pressure.
Hugo speaks from practical experience. “We are already seeing the results at Steve Biko Academic Hospital as well as at the Daspoort Clinic where we are practically applying care co-ordination.” Daspoort Polyclinic is Claremont, Pretoria was established in 1964 by medical students. It is now a practical learning base for UP students from a number of health science disciplines that extends to the nearby informal settlements of Malusi and Zama Zama.
“With co-ordinated care, patients who used to be at our facilities for frequent visits are now well controlled and managed at home supported by community health workers, so they can make fewer visits. It’s not a perfect system yet, but we see that when we commit to co-ordinated care, there is more respect and mutual learning between everyone along the patient care pathway,” says Hugo.
He says: “Once you implement this integrated type of care the efficiency improves. There is far less wastage, because you know where resources are being directed, and costs come down. This model can also be scaled up or down depending on the geographic area, and it can be replicated in any environment.”
Co-ordinated care leans on science and state of the art technology to model and plan service support. Through geographical mapping and the best available data the UP modelling toolkit enables health care services to keep up with changing needs.
But, Hugo says, it is also essentially a return to the basics of patient-centred practice. This requires that healthcare professionals co-operate and communicate with one another to ensure that patients in their care and the people around them are informed, consulted, involved and supported throughout the course of their treatment.
It’s all about “interaction between entities”, making sure that information and knowledge sharing loops through everyone, from specialists to carers and patients, as well as every health and care provider in between.
“Since 2010, Family Medicine has made a deliberate shift to work more directly with our communities, because we know that is the first place where healthcare should be taking place. Our patients include some of the most vulnerable people in the city.
“Health is something that is lived and experienced and is something that happens at someone’s home and at their work, so the concept of co-ordination of care means being able to give patients healthcare at the most helpful place at the right time, and with the right information,” he says.
In April this year the School of Medicine started focusing on the co-ordination of care in the hospital, clinic and service complex around Steve Biko Academic Hospital.
Hugo says co-ordination starts by simply asking every patient: “Where do you come from? Where will you go to when you are discharged? How will you continue to get care when you are there?” He believes that knowing the answers to these three questions gives healthcare providers a clear understanding of a patient’s circumstances and how these may affect their aftercare.
Central to making co-ordinated care a reality, therefore, is the existence of community based services and community health workers (CHWs).
“We need to stabilise the position of CHWs by making their jobs permanent, full-time posts with proper salaries, support, education and training. CHWs must be integrated into the healthcare system and there should be a minimum standard so that service can be predictable,” says Hugo.
It’s CHWs who assess risks and needs of patients in their home. He says the information they provide is healthcare gold. It’s CHWs who are able to pick up problems such as hunger and malnutrition, poor sanitation and hygiene, domestic violence or harmful substance. And it is through them that it is possible to build and retain relationship continuity, an essential part of quality healthcare.
Currently, the 32 CHWs working at Daspoort Polylinic who are supported by UP. They keep patient and household records digitally. This small technological intervention allows them to access relevant information quickly, supports their decision making and enables better record keeping.
At the same time the data CHWs collect feed into management and planning so that resources can be channelled to the right places. And it supports research, which is important to ensure that what is being done effectively contributes to health outcomes.
Hugo says: “This is perfectly in line with the fourth industrial revolution goals of maximising information at a peripheral level and using that information to identity risks, to modify risks and to monitor a service.”
Dr Tshegofatso Maimela from Steve Biko Academic Hospital has a key interest in integrated community health. She says that introducing co-ordinated care into their hospital has fundamentally changed the workplace culture.
“Because all the healthcare professionals from the specialist through to the CHW meet on a regular basis, you end up understanding each other’s challenges.You are able to see where your colleagues may be able to help you with a patient, and it could be something you had never considered before,” says Maimela.
She says co-ordinated care in the hospitals has helped to promote professional respect and collaboration. It has also helped save a lot of time, eliminating duplication across the board from medical tests to basic administrative tasks.
“It may seem like more people are involved in looking at the same patient, but the opposite is true, because at collaboration and communication at every level means that the patient has a better chance of getting to see the right person for the right condition at the right time,” says Maimela.
She says co-ordination transforms well-trained young doctors into more empathetic professionals because they are sensitised to patients’ circumstances outside the hospital environment. Maimela says going into the communities where their patients live is empowering for the doctors and deeply affirming for the communities. Doctors find they are able to use their leverage and agency for the benefit of patients while people in communities no longer feel like they have fallen through the cracks.
One of UP’s newest interventions has been to identify so-called “adherence posts” in Tshwane. These are places where homeless people, who are on treatment, can safely store and easily access their medicines on a daily basis.
For both Maimela and Hugo, coordination of care is about pulling together service providers to ensure that patients and people get care that is effective, appropriate and affordable. Its is about mobilising and building the asset base.
Hugo recognises that this is just the beginning. “Our efforts to co-ordinate care are not always perfect, but they are a good starting point. They will be refined and improved as we get better at working together around the needs of our patients. Anyway they fit squarely in the need to integrate care proposed by the NHI bill.”
He says: “The current disruption of debate around the NHI Bill is an opportunity to look at how we can use our resources to properly care for everyone in South Africa, including the most vulnerable”.