A Review of "Health Care Technology Assessment - 
the South African Health Care System in Transition" 
by Michael Ogembo Kachieng'a and David Boonzaier

Reviewed by Michael Tekletsion Berhan
African Technology Forum
Copyright 2000

 In the South African Medical Journal, Michael Ogembo Kachieng'a and David Boonzaier of the University of Cape Town's Department of Biomedical Engineering published a paper named "Health Care Technology Assessment - the South African Health Care System in Transition" [February 1999, Vol. 89, No. 2, pp. 149-155].  They focus on how health care technology implementation is chosen, budgeted, and provided, the challenges facing such implementation, and how this plays out in the world of South African medicine.

 The picture facing South African medical practitioners - and health care providers everywhere - is laid forward in Kachieng'a and Boonzaier's paper in two sentences that jump out at the reader.  Their stating that "The demand for service involving technology exceeds the supply, and therefore some form of explicit or implicit rationing is inevitable" points to the direct intersection of the harsh economic laws of supply and demand with patient's lives.  They then quote neurologist Oliver Sack's book Awakenings [1]: " 'medicine is asked to transcend the possible'.  The need for assessing technology and managing it efficiently is essential for a successful health care system".  The authors do not intend to say that the task is fully impossible.  They are only highlighting the stark challenges of health care and pointing out that the job of managing the deployment of technology into health care is a rigorous one and one that calls for serious financial discipline.

The authors discuss the process called health care technology assessment (HCTA).  HCTA is presented as the balancing of the clinical efficacy of a technology and the cost effectiveness of deploying that technology.  This balancing can lead to tight razor walks, with a very real risk-management component to handle.  They quote two other sources that cost savings of up to 90% has been demonstrated in a South African renal unit by re-using dialysers [2] and that in Quebec, appx. $5.6 million USD is saved annually by public hospitals cleaning and re-using cardiac catheters [3].  Clearly, these are not simple choices, and are probably quite controversial considering the risk of infection when any medical tool or implant is reused and introduced to the body without truly absolute sterilization.  However, especially in Africa, both hospitals and patients rarely have the budget or range of basic necessities for good medical care.  Such items can actually be more rare than gold, and as such the risks of usage are often outweighed by the option of not reusing these items and losing the patient. 

Kachieng'a and Boonzaier state that "probably the most important contribution of ... HCTA studies is the ability to induce changes in clinical practice.... by sharing the accumulated evidence with the [rest of the] medical profession and the public".  Although the deployment of reliable phone lines and even basic Internet services are few and far between in Africa, the use of the Internet to speed up the sharing of practices and empirical data between professionals, governments, NGOs, and other related will obviously help tremendously.  Hopefully, efforts by the UNDP, UNECA, WHO, and African governments, health ministries, and telecoms will become more focused on the possible impact and tremendous leveraging effect such "lessons learned" networking can have on the African medical community's efficacy.

One important point is the authors' call for increased use of industrial-style "cost center" and "profit center" accounting in African health care management.  It is indeed crucial to track what costs are encountered to provide what services and overall benefits, and what sustaining cash flow is generated or incoming.  Kachieng'a and Boonzaier state "it is usually impossible under most hospital budgeting and accounting systems now in use [in South Africa] to relate revenues and expenses to specific services."  However, industrial experience can point out there are some cautions in this area.  The major one is that cost centers often become "actively neglected" - particularly since the maintenance budgets required to keep these services operating are often treated as only adding to a program's cost.  The focus of maximization of long term service viability, profit (or at least staying within budget for public hospitals), and growth can get lost in the cost-cutting activities that all organizations must experience to stay economical viable.  The long-term return on investment (ROI) of any systemic service can be weakened when one part of the system is neglected.  It often becomes the ever-present doctor vs. the accountant battle when this aspect of financial management is not properly implemented with a "big picture" mindset.  The ROI in question here is the public's ability to stay healthy and productive, both individually and as a whole, and the big picture is the nation's socio-economic life and vitality.  As always, caution is important, and with this valuable financial technique, the "medicine" must not be worse than the "disease" itself.

Kachieng'a and Boonzaier themselves make a strong effort to point to the necessity of proper accounting for maintenance and replacement of equipment.  They state that at the time of publication of their article in February 1999, South African public hospitals have no medical equipment depreciation accounting policy.  There is, therefore, no generally accounted time scale for replacement of the equipment, only fixed costs for supplies and materials.  This can lead to under-accounting for the increased maintenance for aging equipment, and over-accounting of the capital value of the equipment itself in any given fiscal year.  To put this somewhat in perspective, Kachieng'a has found that of 54 hospitals surveyed in South Africa, for hospitals of 75-300 beds, only 1.3% of their facility services budget was targeted for equipment maintenance.  For hospitals of 300-600 beds and for those of over 600 beds, only 1.3% and 3.0%, respectively, of their facility services budgets were slated for equipment maintenance.  These proportions were "far below the 10% of facility budget that is internationally recommended for this purpose", the 10% value being quoted by Kachieng'a and Boonzaier from a World Bank publication, Better Health in Africa: Experience and Lessons Learned [4].  While the deathly thin budgets most African hospitals face can make it a devil's choice between, say, antibiotics for newborns, or incubator maintenance, a long-term balance must be struck where at all possible.  It is peacetime triage at its most concrete and biting. 

Kachieng'a and Boonzaier do a good job of discussing the challenges faced by health care providers in South Africa and elsewhere as they decide what technologies to deploy for the public good, and how to manage this process.  Their focus on technology and equipment is indicative of the next stages that less developed countries face, especially those that have such a range of patient financial status as South Africa.  In what is called the Third World, more countries will be faced with these deployment challenges on more than a simple clinical level, particularly in their population and economic centers.  African policy makers, planners, and health care providers must be as ready as possible to prepare for and manage these challenges, even in light of the already super-human challenges they already face.  A promising, yet sobering, thought indeed.

References per Kachieng'a and Boonzaier's "Health Care Technology Assessment - the South African Health Care System in Transition":

[1]       Sack, Oliver, Awakenings, New York: Harper Collins, 1990: page 266

[2]       Department of Health, "A Health Care Technology Policy For South Africa",
Discussion paper, Pretoria, South Africa: Dept. of Health, December 1997

[3]       Van Zyl Smit R, Pascoe M, "Where do we go from here - the future of
nephrology in South Africa", South African Medical Journal, 1997,
vol. 87: pp. 591-594

[4]        International Bank of Reconstruction and Redevelopment (World Bank),
Better Health in Africa: Experience and Lessons Learned,
Oxford, UK: Oxford University Press, 1995