Quality of healthcare: Is the private sector always better?

It was a warm summer’s day at Mofolo community health centre in Soweto. I was a junior doctor, standing at the front of the clinic at 3pm, desperately trying to triage the hundreds of patients still waiting to be seen. In front of me stood a well-dressed, healthy looking man in his early 30s, his demeanour and formal suit implying education and a white-collar job. Glancing down at his file, I saw that he was a diabetic with a glucose level of more than 20 and other parameters that implied a medical emergency. I was instantly frustrated by not only the implications of a potential medical emergency but the prospect of referring him to an equally overwhelmed facility — Chris Hani Baragwanath Hospital. With a tone of irritation, I asked: “Why did you not take your medication?” He instantly teared up saying, “I dont have money for food.” 

I tell this story often not only because it has many lessons about empathy, social determinants of health or patient and health worker experiences, but because it is a useful reminder to me that I, too, have been that unsympathetic health worker stuck in a system so well-highlighted by the viral social media post by Tom London. 

Although I can empathise with both the patients and the healthcare workers in that video and the temptation exists to decry the public sector and tar everything and everyone in it with the same brush, a more fruitful approach would be to remind us all of what quality healthcare is meant to be and where our failings are. Two recent health system documents, the Health Market Inquiry (HMI) report (2019) and the Section27 Health Reform – Perspectives and Proposals report (2021), provide critical insights into the problems and opportunities for healthcare reform in the country but first:

What is quality care?

While quality care is sometimes referred to only through the lens of infrastructure, there are many dimensions that contribute to quality care including:

• Safety: Ensuring care does not harm patients;
• Effective and efficient care: Providing evidence-based healthcare that maximises available resources and avoids waste;
• Timely care: Reducing delays and long waiting times;
• Equitable care: Delivering care that doesn’t vary in quality based on socioeconomic status, gender or geography; and
• People-centred and integrated care: Offering care that responds to individual needs and preferences throughout the health journey.

So how does our health system measure up against these parameters?

Safe care

Safety in the public sector is often compromised by resource shortages, overcrowded hospitals and inadequate infrastructure. Patients are at risk of medical errors, misdiagnoses and healthcare-associated infections (HAIs), particularly in rural areas. On the other hand, the private sector is generally better equipped, with more advanced technologies and better-staffed facilities, contributing to higher safety standards. But a lack of regulation and governance has led to little transparency and low accountability in the reporting and addressing of safety outcomes in private hospitals and subsequent difficulty in comparing outcomes across the sectors. 

Effective and efficient care

The public healthcare system in South Africa struggles to provide effective care because of budget constraints, staff shortages and inefficiencies in the referral and follow-up process. While the private sector benefits from advanced technology and well-trained staff, contributing to more effective care, the fee-for-service model encourages over-servicing, which can lead to unnecessary treatments and reduced overall efficiency and effectiveness. By way of example, a few years ago, I underwent an expensive and uncomfortable investigation only to realise that the procedure wasn’t even needed when the consulting doctor forgot that they sent me for the tests and promptly scheduled my surgery without the “vital” information they had insisted was needed before we could proceed — a personal experience highlighting that even those with the benefit of medical knowledge have been victim to this overservicing.

Timely care

One of the most significant difficulties  in the public sector is long waiting times for consultations, diagnostic tests and surgeries, leading to worsened health outcomes, especially for chronic conditions. The private sector generally provides more timely care, with faster access to specialists, surgeries and other services but again, this timely care comes at a high cost, limiting accessibility for most South Africans.

Equitable care

The public sector is committed to providing equitable healthcare but, in practice, access to quality care is uneven. Rural areas often lack basic healthcare services, and the system’s inefficiencies disproportionately affect disadvantaged populations. The private sector is inherently inequitable. Access is limited to those who can afford expensive private medical schemes, while the majority of South Africans are left to rely on the under-resourced public system.

Patient-centred and integrated health care

Because of overcrowding and limited resources, patient-centred care is often neglected in the public system. Healthcare workers are overburdened, leading to rushed consultations that fail to fully address patients’ needs and preferences. Patient-centred care should theoretically be more achievable in the private sector because of lower patient-to-staff ratios and better resources. But the fragmented approach to healthcare means that many doctors work in solo practices with very limited team-based care. Additionally, the limited transparency regarding the quality of care and patient outcomes makes it difficult for patients to make informed choices about their provider, although there is more agency for patients regarding provider selection than in the public sector. 

Taking the above into account, a central aspect to all these parameters is “care”, which from Tom London’s video, as well as from the subsequent discourse and my own personal experiences, is severely lacking within our healthcare system. 

I doubt that my colleagues enter the medical field aiming to be callous and profiteering, but a system of overwork and under-resourcing (public sector), coupled with the corporatisation of medicine (private sector) has eroded the ethos and ethics of many healthcare workers. This trickles down through the ranks to our students, who are taught through fear and bullying, and an overall lack of respect for colleagues — ultimately all leading to the dehumanisation of our patients as the most vulnerable in this system. 

The dignity of patients and health workers must be maintained, so although the HMI and Section27 Health Reform reports both paint a detailed picture of the South African healthcare system’s problems and opportunities, we need to focus on the system and its people by:

• Addressing the issues of equity and over-servicing that counterbalance the better safety, timeliness, and effectiveness of the private sector;
• Fixing the chronic underfunding, inefficiencies and safety concerns that erode the equitable intentions of the public sector;
• Enhance collaboration between the two sectors to ensure better governance, and increased transparency to improve patient outcomes and promote a more equitable healthcare system for all South Africans; and
• Ultimately, provide a system supportive and conducive to healthcare workers providing the best possible, high quality care to everyone in need, regardless of financial status

This balanced approach of using the strengths of both sectors — while addressing their respective weaknesses — offers the best path forward for comprehensive healthcare reform in South Africa.

Dr Atiya Mosam is an independent public health medical specialist and founder of Mayibuye Health with interests in strengthening the health system, healthcare financing and economics, and primary health care.