Oncological procedures(Ca oesophagus, sarcoma, melanoma…)

Multidisciplinary approach:driven by breast surgeon

• Oncology Nurse
• NGO involvement:CANSA, SOCAS, BreastSens, Reach for Recovery…
• Palliative care
• Social worker
• Community worker
• Life long follow up:Breast Clinic

Increased complexity of surgery…

• Mastectomy and axillary dissection
• Oncoplastic techniques
• Reconstructive methods:immediate and delayed
• Sentinel node dissection

Breast Unit

• Minimal volumes required
• Staff requirements
• Minimal adjuvant services
• EUSOMA requirements

Immediate problems

• Reduce waiting time: Employ dedicated clerks to work from the clinic, print admission stickers in advance, stable IT system for access to results
• Use of IT technology
• Maintenance requirements: running water and basins for dressing room
• Access to quality radiology: digital mammograms, sonar for clinic, stereotactic biopsy facility, make MRI functional. Solution mobile mammogram unit.
• Pathology reporting delay
• Address bed occupation challenges in Ward 4

Long term goals

• Compliance with international standards(BHGI, EUSOMA)
• Academic output
• Create regional infrastructure:outreach and network
• Interdisciplinary women’s health program
• Integrate other role players, NGOs

Many challenges exist in the current healthcare system inter alia:

Inequitable distribution of spend between two tiers namely a large private sector (60%)  serving a higher income minority while the public sector (40%) serves the majority of the population.

Since 1994 the public health sector has experienced a stagnation in funding allocation, with  a consistent decline in real per capita terms

Inability to effectively treat people with TB.  The incidence of adult TB has risen seeing a threefold increase in numbers of infected people from 1996 to 2006

The mal- distribution of human resources is evident, 60% of nurses and 40% of doctors serve 85% of the population in the public health sector.

There is also a severe undersupply of pharmacists in the public sector resulting in many rural areas having inadequate or no access to pharmacy services and hence no access to medications (especially AIDS drugs)

The National Health Insurance (NHI) will enable an integrated, pre-payment-based mechanism that will ensure that all have access to healthcare. The key objective of the NHI is to solve the problems seen with a dual health system and to promote social solidarity by achieving universal coverage. This change is needed urgently due to the lack of achievement of the MDGs (Millennium Development Goals) for health and the stagnation and even deterioration in mortality rates and life expectancy. An additional rationale for introducing an NHI system is that it would provide a mechanism for improving cross-subsidization in the overall health system, whereby funding will be linked to an individual’s ability to pay while benefits will be determined by an individual’s need for care. This will enhance compliance with our constitution (right to access health care services as well as the underlying determinants of health such as the right to clean drinking water, the right to adequate housing, and the right to a clean and safe environment, the right to sufficient food and nutrition and social security)

An NHI Fund will be established within the provisions of the appropriate laws and regulations. The NHI Fund will be responsible for: receiving funds, pooling the resources and purchasing services on behalf of the entire population. The Fund will be publicly administered as a single purchaser with sub-national offices at the provincial level and will negotiate and contract with service providers. This single payer system will be effective in collecting revenue, distributing risks through one large risk pool and offers government a high degree of control over total health expenditure.

Structure

Minister of Health

CEO (Chief Executive Officer)

Executive Management Team with specific technical committees

Technical advisory committee, audit committee, pricing committee, remuneration committee, benefits advisory committee (BAC) and others

The NHI Fund will be advised by a committee comprising of representatives of the relevant government authorities, the health care providers and representatives of civil society.

The Minister of Health will remain responsible for the overseeing the NHI Fund, the development of NHI policy and any amendments that impact the NHI Fund (changes in demography, epidemiology and health technology development)

The Fund however must remain an independent body; the National Department of Health will continue to be the overall steward of the healthcare system and will remain a major provider of services through its national, provincial and district level structures and facilities. In addition the NDoH will continue to provide non-personal services including overall responsibility for infrastructure development for which it receives a budget. Coordinating the development of overall health plans including personal services will remain the responsibility of the NDoH, the purchasing function for personal services will be the NHI Fund’s responsibility (the Fund will contract directly and reimburse both private and public providers) These purchases will be part of a NDoH-approved purchasing plan.

NHI Healthcare Benefits

The NHI Fund will provide primary, secondary and tertiary care. Quaternary care will remain the responsibility of the NDoH.

Primary care and preventative services

Inpatient care

Outpatient care

Emergency care

Prescription drugs

Appropriate technologies for diagnosis and treatment

Rehabilitation

Mental health services

Full scope of dental services (other than cosmetic dentistry)

Substance abuse treatment services

Basic vision care and vision correction (other than laser vision correction for cosmetic purposes)

Hearing services, including the provision of hearing aids.

The EDL will be the basis for pharmaceutical, medical supplies and devices. This will be updated regularly by the BAC. Emphasis will be on primary health care with referral to specialists and in-patient care. Through a defined allocation of funds the NHI will include personal preventative services according to developments in the disease burden of the covered population. The NHI benefits will be comprehensive but will exclude all medically unnecessary services. This exclusion list will be reviewed at appropriate intervals by the BAC.

Public and private healthcare providers will  be accredited to provide 1^o, 2^o, 3^o and 4^o care. A referral process will be defined for services within and outside the district to assure continuity of care and of cost containment. Private GPs will be encouraged to develop multi-disciplinary practices. The accreditation will be conducted by the National Office of Standards Compliance (OSC) which will report directly to the Minister of Health.

Sources of Revenue and Pooling Functions

The main source of funding will be general taxation and mandatory contribution (at a later stage additional funding e.g. from the Road Accident Fund (RAF), Compensation for Occupational Injuries and Diseases Act (COIDA) will be considered). The mandatory contribution will be progressively structured and collected by SARS. Everyone earning above the income tax threshold (annual adjustment) will make this contribution which will be shared between employer and employee. Additional funding will include the elimination of the current tax-deductions for medical scheme contributions. This will be channeled to the NHI system. Out-of-pocket payments are not seen as funding for the NHI as there will be no charges at the point of service for the insured for the services covered by the NHI. Currently the exact magnitude of the mandatory contribution and that of the general tax funding is still under discussion, however it is agreed that a considerable increase in public funding is essential to meet the financial needs of a publicly funded health system.

Provider Payment Mechanisms: all accredited service providers will be reimbursed on according to a risk-adjusted per capita payment and global budgeting.  The annual capitation amount will be linked to target utilization and cost levels. This will apply to all service providers, private and public in all categories of service provision. Recommendations include that the capitation should be linked to an appropriate index such as CPI, the NHI Fund will assist providers to control expenditure through approved formulae and protocols. At all costs an appropriate level of care must be assured and under-servicing must be avoided. High cost care for services excluded from the list of benefits under capitation will be reimbursed from a separate allocation of the NHI. There will be no co-payments or out-of-pocket payments to accredited providers. (this payment will only apply to the non-insured (tourists) or for health services excluded by the NHI).

Allocation of NHI Fund Revenues: The allocation of funding must ensure the provision of care for the services covered by the NHI Fund whilst maintaining improved quality as well as an incentive to recruit and retain qualified health workers.

Registration of the population will be essential to ensure that all eligible citizens have access to the NHI, initially the green, bar-coded or equivalent legal ID will be used and later all will be issued with an NHI card that will contain all the relevant health information. This will ensure portability of health services.

Information systems and quality assurance: the NHI Fund will contribute to an integrated and improved National Health Information System (NHIS) to facilitate an effective implementation of an NHI system and portability. This will support monitoring of coverage in all population sectors, financial and management functions, utilization reviews, quality assurance programmes for health care providers, report generation for health system management and research documentation to support changes as the healthcare needs of the population change.

Promotion of the NHI system: through a transparent communications programme, a proactive social marketing approach will be taken to increase the knowledge and understanding of the NHI Fund’s functions and activities. This will include raising awareness among politicians and community leaders at all levels to enlist their support, develop and maintain a multi-target educational drive using all relevant elements of communication.

The improvement, expansion and revitalization of the public healthcare infrastructure is critical to achieving a successful implementation of the NHI, hence a parallel health systems strengthening plan has been developed to assure infrastructure maintenance, improvement and expansion (capital costs) and service provision (recurrent costs)

This concurrent Health System Strengthening Plan will focus on

General Infrastructure Inventory and Development, all existing public and private facilities will be assessed to determine their capacity for service delivery and to identify gaps for expansion and development.

Quality primary healthcare will be delivered by a revitalized and adequately financed district health system hence the District Health Councils , nationally, will be strengthened by improving political governance, managerial oversight and accountability structures. These offices will manage the flow of funds from the NHI to the providers.

Mechanisms will be created to increase the efficiency of these public health facilities, especially hospitals, to allow them more managerial autonomy and thereby improve decision making and accountability.

A Human Resources Plan for Health will be developed to increase the supply, quality, distribution and retention of health workers in the country.

Quality Improvement Plan: The capacity of SA healthcare to meet the needs of the community it serves has been examined and factors impairing this ability have been identified. A carefully planned, organized, articulated and documented quality improvement and quality assurance plan is required. This plan is described in depth with all the relevant bodies involved.

Phased implementation of the proposed NHI: because this requires substantial transformation in funding and provision aspects a phased approach will be beneficial. Phase 1: wide consultation to get inputs from public and private, stakeholders (labour, community groups, NGOs, civil society) comprehensive review of existing legislation to draft new legislation and the drafting thereof, increase funding of public sector health services from general tax revenue, revitalization of public health infrastructure, introduce quality improvement and quality assurance programmes and the development of a human resources programme.)

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Georgetown University, Cancer Control Program, Washington, DC 20007, USA.

PMID: 20575210 [PubMed - indexed for MEDLINE]

The breast clinic manages to provide much needed breast healthcare services to the Greater Soweto community and to other surrounding townships. Renowned for its expertise and extensive experience Chris Hani Baragwanath receives specialist follow- up referrals from other public hospitals, among them Sebokeng Hospital, Leratong Hospital and Tembisa Hospital. Most of the referrals are for diagnoses confirmation and surgical procedures.

Chris Hani Bara offers all breast related services like diagnostics which include specialist radiology, pathology, cytology and nuclear medicine. The ultimate goal of the medical team at the clinic is to establish a state of the art breast healthcare facility to deal comprehensively with women’s breast healthcare needs. A one stop shop of sorts where women can be diagnosed and treated; undergo surgery; receive chemotherapy, radiation and hormone treatment as determined by the stage of their disease and recommended treatment protocols.

The clinicians recognize the value of offering cross-over services for these a resource strapped communities. To this end, proposals are being made to equip the new breast clinic facilities so they are additional services like voluntary HIV/Aids testing, screening and HPV vaccinations for cervical cancer. This holistic approach will be a boon in these communities where a lack of financial resources and great distances from primary healthcare centers make it difficult for women to make repeated trips to academic hospitals. Resource limitations significantly hamper patients’ access to healthcare; contribute to an increase in the number of patients lost to follow-up and poor patient treatment compliance.

Knowing the Chris Hani team, there is no doubt in my mind that their goal of establishing this one stop shop attainable.  Their professional abilities, tenacity and dogged determination to deliver world class service under challenging circumstances are sufficient proof. Dr. Cubasch, surgeon and head of the clinic sums the team’s chutzpah up by proudly, but with an air of modesty, stating: “We do not allow our current facility challenges to deter us from striving to provide world class breast healthcare as swiftly we can.” Cubasch continues, “A recent hospital patient waiting times assessment report showed that our unit is continuously improving in curtailing long waits. We will continue to minimize the strain and anxiety experienced by our patients while waiting for consultations.”

The CHB breast clinic has grown over the years. The clinic saw 6056 out-patients in 2009 and diagnosed 352 new cases. About half of these patients with advanced disease – stages III and IV. For this reason the breast clinic is considering forming alliances with Greater Soweto municipal clinics and other primary health centers to educate and make breast services more accessible to women in its catchment node.

Financial and professional resource shortages currently frustrate this much needed intervention. The training of nurse practitioners, and controversially sangomas, in rudimentary breast screening and encouraging them to refer patients to Chris Hani Bara for specialist care is vital to community breast cancer control programs.

There is no dispute that imaging is a key component of any cancer control strategy because of the critical role it plays  in screening, diagnosis and post treatment follow-up examinations. Clinicians on behalf of their patients remain frustrated by the backlog and long waiting periods for mammograms in public healthcare facilities. Dr. Cubasch feels strongly that these delays and service delivery inadequacies are a result of poor resource allocation and planning and that they are counter-productive as they erode  benefits the strides made by his unit. He argues that the imaging challenges are compounded by the unit’s ongoing inability to perform stereotactic biopsies and hook-wire placement due to lack of required equipment.

The clinicians at the breast clinic are adamant that they will not compromise their professional ethics by colluding in the provision of mediocre care to their patients simply because the patients are mostly poor and illiterate. The team’s mission and vision is to be able to give a tertiary service to all who require it. To this end the Chris Hani Breast Clinic needs;

Stereotactic devices for biopsy and hook wire placement essential for diagnosis and treatment of early disease which presents only s clusters of micro-calcification

Suitable digital work stations for adequate medical team as well as doctor-patient interface

Integrated Radiology Information Systems (RSI) and Picture archiving and Communication Systems (PACS) for timely and efficient access to images, interpretations and other data related purposes. PACS has been proven to break down the physical and time barriers associated with traditional film-based image retrieval.

A call to action. Citizen activism has been proven to be a highly effective and powerful social change tool. Make a difference by donating to help the Breast Clinic and BreastSens realize some of the greater community interventions listed above. Every penny can save a life. Go to the home page if you wish to assist. Thank you for your generosity.