The following article was written by Lydia Cairncross, Louis Reynolds and Peter Benjamin who are all steering committee members of The People’s Health Movement South Africa. It was published online by the Daily Maverick.
It is time, right now, to prove that we are serious about equity, solidarity and the slogan of ‘no patient left behind’. We can demonstrate this in the steps we take to move beyond the dystopian binary we are caught in where, for too long, we have normalised the monstrous reality that all lives are not equal in our society nor in our health system.
We are now beyond 10 weeks into the State of National Disaster that was announced to combat the Covid-19 epidemic. One of the key interventions needed during this time, aside from strategies to prevent the spread of Covid-19, was the preparation of our health system to manage the surge of ill patients.
Well, that time has now arrived.
A key mandate for our government in the lockdown was to integrate and pool the resources of our private and public sectors to ensure that, in the words of our Minister of Health Zweli Mkhize: “We will not leave any patient behind.” With roughly equal expenditure in each health system, and the private sector managing only 15% of the population, this integration is one of the critical steps to ensuring quality of care during the pandemic. The fact that approximately 70% of all intensive care beds are within the private sector (the resource most likely to be overwhelmed during our peak), makes this process even more urgent.
But the reality is that right now, patients are being left behind. And they will continue to be left behind if there is not a fundamental shift in how the pooling of our health resources is managed.
Patients are being left behind because at present, on 18 June 2020, your eligibility for a Covid-19 test will depend on whether you have medical aid or not and many people who rely on the public sector simply cannot get a test. Also, the time it takes to learn the result of that test (the turnaround time), if you do not have medical aid will range from 7 – 14 days, rather than the 12 – 48 hours if you do.
Patients are being left behind because historically under-resourced health centres in poor communities in this country do not have adequate high care facilities, oxygen points and emergency transport vehicles to manage the rapid increase in patients presenting with shortness of breath at their doors.
Patients are being left behind because public hospitals are, out of necessity, closing and reducing treatments for other conditions in order to manage the surge in Covid-19 positive patients needing care. This, while in many places, private facilities remain underutilised.
Current public-private agreements between private hospital groups, private specialists and the Department of Health seem to focus more on protecting vested private sector interests rather than on addressing the fundamental issues of access, equity and social justice. This is obviously the case with the Service Level Agreement between the Western Cape Department of Health and independent healthcare specialists, dated 8 June 2020, which, according to the SA Private Practitioners Forum (SAPPF) will “be used as a template for other provinces”.
Firstly, the agreements accept as a given that the resource-constrained public sector must reach full capacity before spilling over to the over-capacitated private sector. This is morally and ethically unacceptable. A system where Covid-19 positive patients are transferred to private facilities only when the public sector is “unable to cope” means that public sector patients, both with Covid-19 and other conditions, will continue to be disadvantaged. This particular agreement states that:
“The acceptance of patients by private hospitals is at the discretion of the private hospital whose principals must be willing to accept the patient.”
In other words, it is optional for the private hospital. Added to this is what appears to be a cumbersome bureaucratic process where patients who have been accepted by a private facility then also need clearance from a Private Provider’s Operations Centre, and an authorisation order from the DOH. It is also stipulated that sick patients with Covid-19 who present at private hospitals and do not have medical insurance, will be transferred to state facilities.
We believe that there is sufficient willingness, goodwill and expression of solidarity from healthcare workers in public and private, and from industry role players in the private sector, to engage in a genuine partnership and sharing of resources.
This is a far cry from the spirit of social solidarity where the resources of private and public sectors are pooled into one comprehensive health response. What this really means is a purely voluntary process for the private sector if “willing and able”, with no collective management of beds and resources nor assessment of burden of illness in hospitals on either side of the divide. It also means that busy, over-stretched clinicians in public hospitals need to engage in time-consuming bureaucratic processes in order to manage the transfer of often critically ill patients where minutes and hours may be critical to survival.
If we add into this the complexity of making difficult resource allocation decisions where there is currently no uniform clinical protocol, we may have a situation where private hospitals have a lower threshold for high care and intensive care admission, and may fill up early and quickly, leaving no space for public sector patients who may be sicker. Public sector hospitals will then be forced to continue to triage and ration their limited resources more strictly to reserve high care and ICU only for those most likely to survive.
Once again, we will then see the cruel and immoral binary health system play out with one standard of care for the rich and one for the poor.
Having outlined the problems with the current agreement, what should a public-private integration based on social solidarity look like?
In principle, we should build, during this pandemic, the foundations of a single, publicly funded health system for the post-Covid-19 era. In the short term, the components of this unified response would be:
- Uniform clinical guidelines across both sectors based on evolving best clinical practice and knowledge.
- Pooling of hospital bed resources, in particular high care and ICU beds, into one integrated platform.
- Partnering specific public and private facilities within geographical areas to facilitate the pooling of resources including hospital beds, PPE, healthcare workers, ventilators and high-flow oxygen machines.
- Establishment of joint Public-Private Covid-19 Medical Response Teams, with clinicians from partner hospitals managing admissions and transfers between facilities with an overarching financial arrangement that does not require individual authorisation for each patient.
- Establish similar public-private partners at community GP and day hospital level to ensure equal management of patients with less severe illness.
This kind of true integration is not unworkable or unprecedented – in March 2020, in the surge of Covid-19 cases in Spain, the government nationalised all of its private hospitals to manage the peak of their epidemic.
The question of financing this model, though not the focus of this article, is important and several writershave addressed this in the recent weeks. But essentially, the principles of remuneration should be at a daily rate, at cost for private hospitals and, for healthcare workers, at a pro-rata rate based on public sector salary scales. Ideally, healthcare workers in private, who are currently under tremendous financial pressures due to the impact of the lockdown on their practices, should be brought into the DOH on contract. Some of these may be full-term contracts as the health need in the public sector will continue and probably increase post the Covid-19 crisis.
It is time, right now, to prove that we are serious about equity, solidarity and the slogan of “no patient left behind”. We can demonstrate this in the steps we take to move beyond the dystopian binary we are caught in where, for too long, we have normalised the monstrous reality that all lives are not equal in our society nor in our health system.
We believe that there is sufficient willingness, goodwill and expression of solidarity from healthcare workers in public and private, and from industry role players in the private sector, to engage in a genuine partnership and sharing of resources. But if this is not the case, it is the mandate and historic responsibility of the DOH and of the people of this country to take over the administration of private health resources in this time of crisis.
We call on the DOH, Treasury, private hospital groups, professional societies, medical schemes and administrators to make the bold and determined changes required to make the commitment to social solidarity by building one health system response to Covid-19 and thereby forging the path to one health system for all in the post-Covid-19-era. DM/MC
Lydia Cairncross is a public sector doctor and activist with the People’s Health Movement of SA; Louis Reynolds is a retired paediatric intensivist and activist with the People’s Health Movement of SA; Peter Benjamin is an activist with the People’s Health Movement