Professional Documents
Culture Documents
APRIL 2010
1 Introduction this year for strengthening the OSC. is a significant departure from global
It appears from the ANCs proposed definitions of accreditation.
national health insurance (NHI) plan3 In this note we consider the implication of
In the Health Ministers recent Health
Budget Vote Speech in parliament, he that accreditation of health providers these two different uses of accreditation.
confirms the future establishment of will be compulsory and a prerequisite In order to inform our discussion we
an independent Office of Standards for contracting with the NHI authority briefly summarise the theoretical role
Compliance (OSC). Minister Motsoaledi (NHIA). However the definition of and benefits of accreditation, before
states that they will audit 25% of health accreditation as used in the proposed considering the ANCs current proposal
establishments annually to assess if they NHI extends beyond the traditional use for a new independent accreditation
comply with core standards for quality. of accreditation in so far as regulating authority in South Africa. We then look
This will be done with a view to accrediting quality; it extends to a type of licensing at international accreditation authorities,
those that meet the standards.2 During mechanism for health facilities and and also discuss potential problems when
his speech, Minister Motsoaledi also providers eligible to provide healthcare using accreditation as a prerequisite for
mentioned that funding will be set aside services under the NHI system. This contracting. A brief assessment of current
This research note forms part of a series of notes dealing with issues of health reform in South Africa. In the interest of constructively contributing
to the NHI debate, the Hospital Association of South Africa (HASA) has commissioned this series of research notes which can be accessed on the
Econex website: www.econex.co.za.
1. WHO, 2003. Quality and Accreditation in Health Care Services: A Global Review, Evidence and Information for Policy, Department of
Health Service Provision, Geneva.
2. Department of Health, 13 April 2010. Available at: http://www.doh.gov.za/docs/sp/sp0413-f.html
3. NEC Subcommittee, 2009. National Health Insurance Policy Proposal. 22 June 2009.
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Trade, Competition & Applied Economics
Structure standards look at the systems inputs, such as human resources, the design of a building, the availability of personal protective
equipment for health workers, such as soap, gloves, and masks, and the availability of equipment and supplies, such as microscopes and
laboratory reagents.
Process standards address the activities or interventions carried out within the organisation in the care of patients or in the management of
the organization or its staff. Process standards for a hospital or health centre might address areas, such as patient assessment, patient educa-
tion, medication administration, equipment maintenance, or staff supervision. Recently, professional bodies have developed explicit process
standards called clinical guidelines. Such guidelines are based on scientific medical evidence (Evidence Based Medicine). Governmental
agencies, insurers and professional bodies are promoting their use in the management of common or high-risk clinical conditions.
Outcome standards look at the effect of the interventions used on a specific health problem and whether the expected purpose of the activity
was achieved. Examples of outcomes, both positive and negative, are patient mortality, wound healing without complications (e.g., infection),
delivery of a healthy infant without complications, and a resolution of an infection through the appropriate use of antibiotic therapy.
4. Rooney, A.L. & Van Oostenberg, P. R., 1999. Licensure, Accreditation, and Certification:Approaches to Health Services Quality, Quality Assur ance
Methodology Refinement Series, USAID.
5. Shaw, C.D., 2004. Developing Hospital Accreditation in Europe, WHO Regional Office for Europe.
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Trade, Competition & Applied Economics
Accreditation standards across the world and management of health services; 3 The Current Proposal
have recently begun to increasingly Establish a comparative database of
include more outcome based standards healthcare organizations able to meet As was confirmed by Minister Motsoaledi,
where the quality of a healthcare facility selected structure, process, and outcome it is envisaged in the proposed NHI
is determined not only by the type standards or criteria; plan that a National Office of Standards
of equipment it has or the processes Reduce healthcare costs by focusing Compliance (OSC) will be established in
it follows, but more importantly by on increased efficiency and effectiveness order to accredit all public and private
the results of treatment and patient of services; sector health service providers (primary,
satisfaction. Many accreditation Provide education and consultation secondary and tertiary care) under the
organisations have developed new to healthcare organizations, managers, NHI.8 It was mentioned above that
performance indicators that measure and health professionals on quality accreditation will be a pre-requisite for
patients experience and the outcome improvement strategies and best contracting with the NHIA and receiving
of health service delivery. In this way practices in healthcare; payments for claims related to NHI
accreditation provides information Strengthen the publics confidence in patients. Accreditation will be phased in
that most frequently is not available to the quality of healthcare; and over a 5-year period, aiming to accredit
the public or even the hospital/clinic Reduce risks associated with injury 25% of all providers each year.9 General
itself, healthcare professionals or the and infections for patients and staff.7 practitioners (GPs) in multi-disciplinary
regulatory authorities.6 Search costs in practices will also be accredited, but GPs
terms of locating an appropriate provider Hospitals or clinics may want to be in areas with human resource constraints
or determining which provider would accredited for any of the above reasons, will still be allowed to provide services to
be best for a specific service, will also but also because it increases the public NHI patients, while being encouraged to
be reduced if credible information is image and accountability of the facility. develop multi-disciplinary practices and
provided freely. For this reason, accreditation is voluntary obtaining accreditation. There is however
Additional positive externalities and in most countries, but there are a few no indication in the NHI plan as to what
purposes of accreditation include the examples of mandatory accreditation. the process may be in areas where an
following: In these cases accreditation is usually artificial shortage of providers is created
linked to financial reward, or it can be because of providers not meeting the
Improve the quality of healthcare by a pre-requisite for reimbursement or accreditation criteria. With accreditation
establishing optimal achievement even contracting with funders. Whether as a pre-requisite for reimbursement,
goals in meeting standards for healthcare accreditation will be mandatory or not, the OSC will therefore serve a dual
organizations; is an important decision on the road to function in assuring/improving quality
Stimulate and improve the integration health reform. and licensing providers to contract
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Trade, Competition & Applied Economics
with the NHIA. Since the proposed costs of accreditation in terms of time, this fragmented nature of accreditation
accreditation authority will accredit money and dedicated personnel, are too authorities in the UK, the United
healthcare providers in an attempt to burdensome on individuals. England Kingdom Accreditation Service (UKAS)
ensure high quality service delivery, as is an example of a country where was established by the government
well as indicate eligibility to serve NHI accreditation is voluntary, and healthcare to accredit the various authorities (or
patients, the formal definitions in Table 1 facilities serving National Health Service evaluators as they are called). UKAS
illustrate that the OSC will provide both (NHS) patients are not accredited by is the sole national accreditation
accreditation and licensure services. In one single organisation. In 2001 there body recognised by government to
addition, the ANCs plan states that this were more than 35 accreditation assess, against internationally agreed
authority will also provide certificates authorities with a wealth of standards standards, organisations that provide
to those healthcare providers who only and trained assessors but little integration, certification, testing, inspection and
fulfil certain requirements or attain some consistency, or reciprocity between calibration services. Accreditation by
standards, but cannot be accredited yet. them.11 There also exists a number UKAS demonstrates the competence,
There is a number of potential problems of umbrella bodies which oversee and impartiality and performance capability
when an organisation attempts to serve support the accreditation processes of these evaluators.13
all these functions, but before considering and authorities. First established as the However, accreditation remains
these in more detail, we first look at other Kings Fund Organisation Audit, CHKS voluntary and is not a prerequisite for
accreditation authorities globally. is the largest independent accreditation payment under the NHS. More similar
body in the UK combining the work to the ANCs envisioned OSC for
and expertise of three established South Africa, the National Agency for
4 International Accreditation accreditation programmes regarded as Health Accreditation and Evaluation
leaders in the field of voluntary healthcare (ANAES) is the only authority in France
Authorities
accreditation in the UK: The Health which is responsible for the mandatory
Quality Service (HQS), the Healthcare accreditation of all healthcare facilities
If one considers the use of accreditation Accreditation Programme (HAP) and serving the French national health
internationally, it seems that only a the Accreditation and Development of insurance patients. This is one of only a
few countries have implemented Health Records Programme (ADR), now few mandatory accreditation systems in
accreditation programmes for individual known as PRIMAP.12 This organisation the world. ANAES is a public organisation
doctors or other healthcare professionals is completely independent of government jointly funded by the government, the
(as opposed to healthcare facilities), and and accredits both public and private public healthcare system, and the
with limited success.10 It seems that the healthcare facilities. In response to healthcare institutions.14 It is important
ECONEX Services
Econex has extensive experience in Competition Economics, International Trade and Regulatory Analysis. Strategic analysis was recently added as
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10. Montagu, D., 2003. Accreditation and Other External Quality Assessment Systems for Healthcare: A Review of Experience and Lessons Learned,
DFID, Health Systems Resource Centre, London.
11. Shaw, C.D., 2001. External assessment of health care, British Medical Journal, Vol.322, pp.851-4. (p.853)
12. United Kingdom Accreditation Forum (UKAF). Available at: http://www.ukaf.org.uk/HAQU.htm
13. United Kingdom Accreditation Service (UKAS). Available at: http://www.ukas.com/about-accreditation/about-ukas/default.asp
14. Pomey, M-P., Franois, P., Contandriopoulos, A-P., Tosh, A. & Bertrand, D., 2005. Paradoxes of French accreditation, Quality and Safety in Health
Care, Vol.14, pp.51-5.12. United Kingdom Accreditation Forum (UKAF). Available at: http://www.ukaf.org.uk/HAQU.htm
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Trade, Competition & Applied Economics
to note the size of this central organisation Figure 1: Development from first to second round of accreditation in France
- this authority has more than 400 full-
time staff members, including health 800
750 100 313 750 750 750
professionals and health economists,
700
with an additional pool of over 3,000
external practising healthcare experts, 605
Number of HCOs accredited 600
including 780 surveyors.15 In 2008 the
operational budget was EUR 66.2 million 500
15. Haute Autorit de Sant, 2008. Annual Report, Summary. Available at:
http://www.has-sante.fr/portail/plugins/ModuleXitiKLEE/types/FileDocument/doXiti.jsp?id=c_868431
16. Average exchange rate for 2008: R 12 = 1 (www.oanda.com)
17. Bruneau, C., 2009. Should Accreditation be a Legal Requirement? Benefits and risks of a mandatory approach, Presentation at the 26th Interna-
tional ISQua conference, Dublin, Ireland, 11-14 October 2009.
18. See footnote 1.
19. See footnote 11.
20. See footnote 10.
21. Medicare and Medicaid are state-funded health insurance schemes in the USA for people over 65 and people with low incomes, respectively.
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Trade, Competition & Applied Economics
associated constraints especially given includes the accreditation of GPs with the organisation should be independent
that accreditation of a health facility multi-disciplinary practices and all from government, even if it is funded
usually takes at least 3 days22 on site primary care facilities. This will place (or partially funded) by government
and there are approximately 396 public an additional burden on the OSC, since to ensure that both the private and
hospitals and 211 private hospitals23 all providers have to be accredited to public sectors are held to the same
in South Africa that will have to be contract with the NHIA. Incentives standard to ensure equity in access. An
accredited if all hospitals are to be part are usually better aligned when the example of a consequence of mandatory
of the NHI provider network. As was accreditation programme is voluntary, accreditation by a parastatal organisation
explained before, the ANCs plan also but if accreditation is required by law, is that of ANAES, the accreditation
Independent, NGO
Canadian Council on Health Services
Canada (in some provinces government gives a Yes Public & private
Accreditation (CCHSA)
financial incentive for accreditation)
National Agency for Accreditation and Independent public agency, partially fund-
France No Public & private
Evaluation in Healthcare (ANAES) ed by government
Japan Council for Quality Health Care Independent, but founded in association
Japan Yes Public & private
(JCQHC) with government
Malaysia Malaysian Society for Quality in Health Independent, NGO Yes Public & private
Hospital Quality Improvement and Ac- Independent, but partially funded by gov-
Thailand Yes Public & private
creditation Institution ernment
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Trade, Competition & Applied Economics
authority in France: due to the process to the total costs of accreditation, as 6 Current Accreditation in
being compulsory, it is perceived as an there would have to be a separate South Africa
inspection from the government, rather policing function focused on detecting
than an assessment of compliance with these events and preventing providers
Accreditation is completely voluntary in
certain quality standards. Care should from under-reporting.
South Africa at the moment. The Council
be taken to avoid turning this system Another potential concern with the
for Health Services Accreditation of
into a wasteful bureaucratic exercise. currently proposed accreditation system, Southern Africa (COHSASA) is the
Further weakening trust in ANAES i.e. attempting to both license and only local accreditation organisation.
is the fact that government budget accredit providers simultaneously, is COHSASA is a non-profit, independent
allocations to healthcare facilities are the different periodicities of the two organisation which accredits both private
linked to accreditation reports.24 Pomey objectives. Licensing is usually a once- and public facilities. Healthcare facilities
et. al. (2005:54) warns that combining off event, signifying compliance with are assessed in terms of the International
the objective of quality improvement minimum standards or qualifications, Society for Quality in Health Care25
through accreditation with that of whereas accreditation is usually valid (ISQua) standards which have been
resource allocation or financial sanction
for two or three years after which a modified for South Africa and comprise
could be problematic, Such a use would
facility has to be accredited once again, of two sections, namely (1) healthcare
have the effect of diminishing if not
indicating the ongoing achievement of organisation management, and (2) patient
cancelling the benefits of accreditation
specific standards of high quality service care.26 In light of our discussion above,
as a learning tool in favour of a system of
delivery. It is not clear from the ANCs this is an important point since the
penalties. This is an important point for
proposal whether the accreditation of ANCs proposal suggests that the OSC
consideration in the South African health
healthcare providers by the OSC will will also use ISQua standards to accredit
reform process especially given the
be a once-off event, or be repeated healthcare providers.
ANCs current proposal of a mandatory
every two to three years (potentially also COHSASA may be able to assist the
accreditation system.
problematic for the initial 5-year phase- proposed new OSC, but there are many
The incentive to under-report negative
events is present in both voluntary and in period if this is the case). obstacles that will have to be overcome
mandatory accreditation systems, but Independent of whether accreditation before the establishment of such an
can be even further encourage under a will be a once-off event or a continued, authority. For instance, at the moment
mandatory system where public budgets repetitive process, it will be a mammoth COHSASA accreditation is voluntary
are determined by the level of compliance, task for the new authority. It is in this and they charge for accreditation, but
or where it is a pre-requisite for context that the current draft NHI if accreditation is made mandatory, the
reimbursement. In those cases, providers plan states that efforts will be made to government will have to decide whether
will have an incentive not to report all identify existing accreditation authorities it will be state-funded or not. Compared
negative events to the accreditation in South Africa, in order to assist with to COHSASA, the OSC will also require
authority (such as accidental deaths due the proposed accreditation process. many more expert/trained staff, increased
to the providers negligence, for instance). The next section assesses the existing funding and more time to accredit all
This phenomena also adds considerably accreditation process in South Africa. healthcare facilities in South Africa. The
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Trade, Competition & Applied Economics
focus will also be somewhat different with processes in South Africa, the envisaged depending on whether accreditation is
a greater emphasis on quality and outcome OSC is a much needed organisation that compulsory or voluntary. The government
standards than what is the case currently. will requiring careful thought and planning should first decide what its goal is
Some of the private hospitals in South to ensure its proper functioning. Such an with accreditation, because if it is the
Africa are accredited by the International organisation will be fundamental to the improvement of quality or the delivery
Organisation for Standardisation (ISO) rather operation of the NHI, and pivotal in the of high quality services, mandatory
overall health reform process.
than COHSASA. ISO develops and publishes accreditation may not necessarily be
international standards for many different the best option. Voluntary accreditation
product and service delivery areas. The aim associated with certain financial rewards
is to facilitate international standardisation
7 Conclusion may be a wiser choice in the South African
across countries and also between private context where quality improvement is vital
and public sectors in manufacturing and This note showed that across the world, in order to improve delivery and outcomes
service delivery. In other words, ISO accreditation is most often voluntary and in our healthcare system. Most importantly,
accreditation for hospitals in South Africa therefore used as a method for improving the accreditation authority should be an
implies that those hospitals comply with quality, rather than being mandatory independent quality regulator that applies
specific international standards focused and a pre-requisite for contracting or the same standards to both the public and
at the healthcare sector. ISO accreditation a determinant of government funding. private sectors.
has been very useful in the South African Where accreditation is a pre-requisite for However, given our understanding of
context in terms of setting standards and contracting, as is the case in France, there the current proposal for compulsory
ensuring high quality service delivery in is a central organisation responsible for accreditation as a pre-requisite for
this sector. These standards may also be a accreditation with a large budget and many providing services to NHI patients, the
starting point for the proposed OSC. permanent and temporary staff members. following Health Reform note will consider
Therefore, even though there are good, The incentives that a provider faces in order the practical implications of establishing
internationally comparable accreditation to be accredited are completely different such an authority in South Africa.