Healthcare Service delivery efficiency; performance of gauteng hospitals

HEALTHCARE SERVICE DELIVERY EFFICIENCY: PERFORMANCE
OF GAUTENG HOSPITALS
Nwauka Oliver Ibewuike
A project report submitted in partial fulfilment of the requirements for the degree of
Master of Engineering (MEM)
In the
GRADUATE SCHOOL OF TECHNOLOGY MANAGEMENT,
FACULTY OF ENGINEERING, BUILT ENVIRONMENT AND
INFORMATION TECHNOLOGY,
UNIVERSITY OF PRETORIA
Supervisor
Dr Richard Weeks
21 October 2013

Healthcare Service Delivery Efficiency: Performance of Gauteng Hospitals
21 October 2013 i
Abstract
There is a general perception that public healthcare service delivery is deteriorating
severely, despite government commitments to change this. This dysfunction stems
from the cumulative impact of burden of diseases, economic pressures, population
surge, policy and strategy incoherence and managerial incompetence. The core
objective of this qualitative research study therefore, is to gain insight into the cause-
effects of this minimal performance, patients’ dissatisfaction and the waste of
resources in Gauteng’s public healthcare sectors, with an intention to provide
recommendations in resolving this crisis and to further research on this subject.
This exploratory study used Performance Assessment Tool for quality improvement
in Hospitals (PATH) framework and Data Envelopment Analysis to evaluate the
satisfaction levels, performance and technical efficiencies of public hospitals
compared to the private sector.
The findings agree that the satisfaction of patients is poor, performance sub-minimal
and technically inefficient and health outcomes unsatisfactory relative to private
hospitals. Public healthcare patients’ service dissatisfaction level was 76% relative to
private sector’s 8%. The efficiency constant returns to scale (CRS) were (40%),
(63%) and (100%) respectively for district, regional and private hospitals while the
corresponding variable returns to scale (VRS) were 41%, 84% and 100% with scale
efficiency score of 97%, 75% and 100 % in that order. Health outcomes such as
patients re-admission within a 28-day period recorded 20%, 21%, <5% for the district,
regional and private hospitals respectively, and PHC health outcome (25%).
The lack of patient satisfaction, performance slack and inefficiency resulted partly
from overall poor decision-making abilities on the use and allocation of resources and
the lack of integrated information systems in the facilities.
Efficiency and performance remain functions of transformational changes involving
leadership, policies, innovations and models of care in the health system. The
reorientation of the system must include review of the funding system, remuneration
of service providers, ownership of the healthcare delivery organisation and system
accountability.
Keywords: Delivery, Diseases, Efficiency, Gauteng, HealthCare, Hospitals,
Information, Patients, Performance, Private, Public, Satisfaction, Service, Innovation.

21 October 2013 ii
Acknowledgements
Special thanks goes to the Almighty for the strength, sense of direction and his
benevolent mercy for the successful completion of this task.
My immeasurable gratitude goes to Mary Jane, my lovable wife for her support, love,
and encouragement especially during the course of this work. To Craig, Marlene and
Christine-Pearl, I remain grateful for your understanding and patience during the
course of this work.
My mentor, Dr Richard Weeks, I remain grateful for your guidance, all round
technical assistance, the sparing of your precious time for me and being
compassionate throughout this period.
This research could have been unsuccessful, if it had not been for the tremendous
assistance of Emrouznejad A. (PhD) of Aston University, United Kingdom, who
willingly released his various published articles on technical efficiency in sub-Saharan
Africa, with such short notice; C.W Folcher (PhD) for her inevitable role in ensuring
that the research was approved by the private hospital.
Very special thanks goes to groups, individuals especially the staff, management of
the Gauteng Provincial Department of Health, and the Johannesburg health district
for their permission to use their facilities.
To doctors C. Kalu, M. M Modise and V. Molepe your assistance during the course of
this research has been invaluable, thank you.

21 October 2013 iii
Table of Contents
Chapter 1: Background to the Research Study ............................................................1
1.1. Introduction...............................................................................................................1
1.2. Rationale of the Research......................................................................................2
1.3. Problem Statement..................................................................................................4
1.4. Importance of the Problem.....................................................................................4
1.5. Research Objectives...............................................................................................4
1.6. Limitations and Assumptions of the Research....................................................5
1.7. Conclusion................................................................................................................5
Chapter 2: Review of Literature.........................................................................................6
2.1. Introduction...............................................................................................................6
2.2 Health Review ..........................................................................................................6
2.2.1 Demographics..................................................................................................6
2.2.2 Gauteng Healthcare Overview ......................................................................8
2.2.3 Health Assessment .........................................................................................9
2.3 Health Strategies Review.....................................................................................12
2.4 Human Resources.................................................................................................15
2.5 Health Expenditure................................................................................................15
2.6 Healthcare Service Performance ........................................................................17
2.7 Healthcare Service Satisfaction ..........................................................................18
2.8 Hospitals Efficiency in Gauteng ..........................................................................19
2.9 Gauteng Public and Private Healthcare Service Overlaps .............................20
2.10 Conclusion..............................................................................................................21
Chapter 3: Conceptual Theories and Performance Models.....................................22
3.1. Introduction.............................................................................................................22
3.2. Healthcare System and Governance Concept .................................................22
3.3. Hospital Levels and Service Structure ...............................................................24
3.3.1. Primary Healthcare (PHC) ...........................................................................24
3.3.2. Hospital ...........................................................................................................26
3.4. Healthcare Technology Innovation Concept .....................................................28
3.4.1. Integration of Health Information Systems ................................................30
3.4.2. Healthcare Innovation Conceptual Framework ........................................31
3.5. Performance Assessment Framework...............................................................33
3.5.1. Outcome Based Performance Assessment Framework .........................33
3.5.2. Performance Assessment Tool for quality improvement in Hospitals
Model (PATH)……………………………………………………………….34
3.6. Healthcare Service Delivery Concept ................................................................37
3.6.1. Service Delivery Models...............................................................................40
3.7. Healthcare Efficiency Concept ............................................................................42

21 October 2013 iv
3.7.1. Related Efficiency Terms .............................................................................44
3.7.2. Application of Data Envelopment Analysis (DEA)....................................45
3.7.3. DEA Limitations .............................................................................................48
3.8. Conclusion..............................................................................................................48
Chapter 4: Research Design and Methodology ..........................................................49
4.1. Introduction.............................................................................................................49
4.2. Qualitative Research.............................................................................................49
4.3. Qualitative Research Methods ............................................................................50
4.4. Advantages of Qualitative Research ..................................................................51
4.5. Basics of the research ..........................................................................................52
4.6. Research Design...................................................................................................52
4.6.1. Research Method ..........................................................................................53
4.6.2. Purpose and conceptual context.................................................................53
4.6.3. Validity.............................................................................................................55
4.7. Conclusion..............................................................................................................56
Chapter 5: Results...............................................................................................................57
5.1. Introduction.............................................................................................................57
5.2. Demographics Data...............................................................................................57
5.3. Service Indicators ..................................................................................................59
5.3.1. Nature of Service and Patient centeredness (Satisfaction) ....................59
5.3.2. Service Availability and Resource Allocation ............................................60
5.3.3. Facility Capacity and Service Utilisation ....................................................61
5.3.4. Information Systems and Technology Innovation ....................................63
5.3.5. Governance (Leadership) ............................................................................65
5.3.6. Government Policies and Strategies ..........................................................66
5.3.7. Health Outcomes...........................................................................................67
5.4. Result Analysis.......................................................................................................68
5.4.1. Service Gaps between Public and Private Healthcare Sectors .............71
5.5. Conclusion..............................................................................................................72
Chapter 6: Conclusions and Recommendations........................................................73
6.1. Introduction.............................................................................................................73
6.2. Performance Recommendations ........................................................................73
6.3. Recommendations for Further Research ..........................................................78
6.4. Conclusion..............................................................................................................79
References............................................................................................................................80
Appendices...........................................................................................................................89

21 October 2013 v
List of Figures
Figure 2.1: Gauteng Provincial Health Services Structure ...............................................8
Figure 2.2: Trends in South African Mortality....................................................................11
Figure3.1: Concept of Health System and Public Health Boundaries ..........................23
Figure 3.2: Health Monitoring Committees ........................................................................23
Figure 3.3: South African Health Delivery System...........................................................25
Figure 3.4: Types of Healthcare Innovation ......................................................................29
Figure 3.5: Health Information Exchange ..........................................................................30
Figure 3.6 How increasing value increases information intensity.................................31
Figure 3.7: Healthcare Innovation Framework..................................................................32
Figure 3.8: A Win-Win Innovative Transformation ...........................................................32
Figure 3.9: Performance Framework Showing the Health Outcomes ..........................34
Figure 3.10: PATH Conceptual Model ...............................................................................35
Figure 3.11: Performance and Quality Measures (Triad Interactions)..........................36
Figure 3.12: Determinants of Performance .......................................................................37
Figure 3.13: Systematic View of Service Delivery............................................................38
Figure 3.14: Changing Value Dimensions.........................................................................39
Figure3.15: Citizen Health Decision Approach................................................................39
Figure 3.16: Six Domains of Performance Interventions ................................................42
Figure 3.17: Topology and Types of Efficiency ................................................................43
Figure 3.18: Determination of Hospital Efficiency Using DEA Analysis........................46
Figure 3.19: Hypothetical Illustration of Technical Efficiency .........................................47
Figure 4.1: Research Methods............................................................................................49
Figure 4.2: Qualitative Research Methods........................................................................50
Figure 4.3: Interactive Model of Research Design...........................................................52
Figure 5.1: Production Possibility Frontiers indicating the Efficiency Trend Using the
Input/Output mix of the Hospitals........................................................................................70

21 October 2013 vi
List of Tables
Table 2.1: Gauteng Public Hospitals / Levels .....................................................................7
Table 2.2: Demographic Indicators of Gauteng Province (Extract) .................................8
Table 2.3: Past 15 years Accomplishments and Shortcomings of South African
Health ........................................................................................................................................9
Table 2.4 South African Health Review for First Quarter 2011......................................10
Table 2.5 Provincial Health Expenditure (Rands in millions)..........................................16
Table 3.1: Stakeholders Needs, Wants and expectations ..............................................28
Table 3.2: Key Hospital Performance Dimensions ..........................................................35
Table 3.3: Evolution of Service Delivery Models .............................................................40
Table 3.4: Service Delivery Models with Improved Competencies ...............................41
Table 3.5: DEA Analysis using a hypothetical illustration ...............................................47
Table 5.1: Hospital Variables...............................................................................................69
Table 5.2: Efficiency Ratios of the Hospitals.....................................................................70
Table 6.1: Performance Recommendations ....................................................................73

21 October 2013 vii
List of Acronyms/Definitions/Abbreviations
AIDS Acquired Immune Deficiency Syndrome
CHC Community Health Centres
DEA Data Envelopment Analysis
DOH Department of Health
GEMS Government Employees Medical Scheme
HIV Human Immunodeficiency Virus
JSE Johannesburg Stock Exchange
MCH Mother and Child Healthcare
MDG Millennium Development Goal
MSTF Medium Term Strategic Framework
NHA National Health Act
NHI National Health Insurance
NHS National Health System
NHP National Health Plan
NSDA Negotiated Service Delivery Agreement
PHC Primary Health Care
SADI South African Development Index
SAHI South African Health Index
SADS South African Demographic and Health Survey
WHO World Health Organization
VCT Voluntary Counselling Test

Chapter 1: Background to the research study
21 October 2013 1
Chapter 1: Background to the Research Study
1.1. Introduction
Efficient service delivery in public hospitals is not a concern to the patients and the
community alone but also to the state. The healthcare sectors’ mandate is to
develop, organise and deliver an integrated and comprehensive healthcare practise
and service to match international norms, ethics and standards and to create values
to meet patients and providers expectations, needs and levels of satisfaction
(Lehohla, 2006:24; Soumya, Eckhard, Pomeroy & Rowan, 2009:9). To achieve this,
the healthcare services focus on patient care and management of healthcare
facilities for which mandates are derived from the South African Constitution, The
National Health Act , provincial enactments and The Council for Health Services
Accreditation of Southern Africa (Department of Health, 2005:76) and the Municipal
Structure Act (Balfour, 2007:4).
Considerable pressure is on the available limited resources due to increased service
demands from the public. Department of Health (2011:18), Zere, Tumuslime, Walker,
Kirigia, Mwikisa, and Mbeeli (2010:10) argue that the shortages of healthcare
resources resulted from macro-economic performance, budget cutbacks, population
explosion, the AIDS pandemic and increasing incidence of injuries and diseases.
These researchers agree that both internal forces and external factors marred efforts
to achieve this, exerting pressure on the costly needed skill, materials and,
technology. The bureaucratic procedures and management process worsened these
problems, making it difficult for the workforce and medical expertise to function as a
system, creating service gaps to favour the private sector in areas of patient
satisfaction and resource emancipation for the stakeholders (Zere et al., 2010:10).
The cause-effect of this shows South African hospitals consuming an average of 50-
80% of resources that accounts for 11% of the overall budget of the government
(Department of Health, 2005:4; Msimang, 2005:5; Zere et al., 2010:10). Of the 8.7%
of the gross domestic product (GDP) allocated to health, the private sector utilizes
5.2%, this accounts for only 20% of the 50 million of the population, and the rest
(3.5%) goes to the public sector that serves 80% of the population (Department of
Health and Global Health, 2005:3; Gauteng Department of Health, 2011:21; Lehohla,
2006:5; Ngwenya, 2007:164).
This notwithstanding, the performance efficiency of the healthcare sector service
delivery has been poor and is feared deteriorating with the rising demographic of ill-
health in South Africa (Cullinan, 2006:2; Global Health, 2005:3; WHO, 2009:10).
Taylor (2009:1) in a report on “Healthcare Reform in South Africa” argues that poor

21 October 2013 2
health services is not entirely due to funding but also the result of cronyism, fraud,
poor working conditions, low remunerations to professional staff, and appointment of
unqualified managers. Information dispersion, ineffective communication and
unstandardized protocol are evident in the public healthcare sector (Motsoaledi,
2011:7). Other influencing factors include the rapidly changing and complex
technology, human development, policy regulations and global shift from process
oriented to result oriented performance (Department of Health, 2005:76; Motsoaledi,
2011:7). In addition, the lack of integrated health information results in deficiencies in
performance process causing long waiting times at the registration process (Global
Health, 2005:3), hence several protests against the dissatisfaction of patients and
service inefficiencies.
These challenges, Motsoaledi (2010:2) warns cannot be minimized if no effective
methods are devised to check, manage, monitor and control the use of resources
especially in the areas of skill; technology; drug and finance; revalidation of health
strategies and policies and review of health status with reduced political
bureaucracies.
1.2. Rationale of the Research
The rationale for this research study stems from a number of critical issues, namely:
 The South African demographic and health survey shows that South Africans
are not healthy (Day & Gray, 2011:7; Department of Health, 2005:9; Global
Health, 2005:3; WHO, 2009:10) and South Africa ranks low in health sector
performance compared to other developing and developed countries
(Msimang, 2005:5).
 The lack and denigration of skills in the country resulting from a shortage of
health professionals and the problem of brain drain in all healthcare sectors is
justified as a key cause of its minimal performance (Department of Health,
2011:18; Clarke, Schoeman & Friedman, 2007:1).
 The Private sector is accessible to 20% of the population and consumes more
than 60% of the healthcare budget (Ngwenya, 2007:164) employing more than
70% of health specialists (Lehohla, 2006:5).
 The public sector faces the challenge of transformation and re-organisation,
budget reform and enhancement of the quality of care and human resource
management (Lehohla, 2006:24).
 Social and cultural orientation and a change in lifestyle patterns could have
influenced patients to have unrealistic expectations and hospitals to display
unexpected service failures, which culminates in the perception of low
healthcare service performance (Murray, 2008: 17).
 A well performing health system, characterised by greater equitability,
efficiency and sustainability of health service outputs delivers accessible, high

21 October 2013 3
quality and affordable curative and preventive services, (Soumya, et al.,
2009:9).
 Emphasis on the need for constant monitoring of hospital productivity,
necessitated by limited resources and unlimited health needs (Kirigia,
Emrouznejad, Cassoma, Zere & Barry, 2008:5).
 The need to adopt an outcome based approach to service delivery with a
focus on efficiency to achieve the Negotiated Service Delivery Agreement
(NSDA) objectives (Motsoaledi, 2010:2).
 The challenges facing the health sector being poor quality of services; poor
equipment; procurement practices; inadequate skills mix; communication;
knowledge and information access; population surge; several complaints;
shortage of health workforce; use and allocation of limited resources and the
spiraling cost of services (Motsoaledi, 2011:7).
The following narrative summarises a common incident in healthcare service delivery
observed recently in one of the South African public hospitals:
“Joe, a 34 year old male with fee-for-service coverage suddenly developed pain on
the on the left hand side of his chest. The pain was so severe that he requested the
sister to call an ambulance that never arrived to take him to hospital. On getting to
the hospital, the registration process took long, as there was only one frontline staff
member serving many people in the queue. Meanwhile, Joe was still groaning in pain
holding his left part of his chest.
At the casualty, a registered nurse next to Joe ignored to call the doctor or even care
to assist Joe in the triage room. The non-responsiveness of the nurse worried other
outpatients who drew her attention to Joe. Still enjoying the heater warmth, Joe’s
sister persuaded her to call the casualty doctor for Joe, who was now lying on the
floor. While the casualty doctor was still ascertaining why he was not notified early,
Joe ‘crashed’ (died).”
The above narrative shows several healthcare service pitfalls such as a lack of
responsiveness, timeliness of care, unreliability, non-accountability for the care of the
patient and communication inadequacies from both ambulance units and the nursing
staff. The shortage of staff and long waiting time at the registration process also
complicated the incident and prevented the problem of myocardial infarction from
being averted, which would have been possible with early intervention by the doctor.
These challenges cannot be minimized, if no effective methods are devised to check,
manage, monitor and control the use of resources especially in the areas of skill,
technology, drug and finance. Strategies and policies need to be revalidated, the
health status reviewed and political bureaucracies reduced.

21 October 2013 4
1.3. Problem Statement
According to “Healthcare in a Democratic South Africa” (Department of Health, 2005:
24) report, healthcare service delivery is a tenet based on the Batho Pele Principle,
the Patients’ Rights Charter, the National Health Plan 2011, the (WHO) targets and
the Millennium Development Goals’ (MDG) expectations. General opinions show that
the demands on the health service system exceed service capacity that lead to the
acclaimed service failure due to poor performance.
These issues and its preceding discussions led to a thought provoking statement to
this exploratory research study:
Trying to get to the cause-effects of inefficiency prompted other challenging
questions such as:
 What performance and efficiency standards exist?
 What effective assessment methods are used?
 What service gaps exist between public and private hospitals?
1.4. Importance of the Problem
The impact of poor performance of the public health sector service delivery seen in
the long waiting times, complaints, protests, rude and uncaring staff, waste of
resources and medical errors have created great dissatisfaction effects amongst all
stakeholders. This problem also created service gaps between the public and private
healthcare facilities. Evaluating and assessing the health system on the needs of
patients is of paramount importance to hospitals’ management, the government and
to the patients, to ascertain the reasons for their loss of confidence in these public
healthcare facilities. Motsoaledi (2011:10) insists that updating efficiency in the health
system will also ensure that the delivery of healthcare services is planned, monitored
and managed appropriately to ensure reduction of waste.
1.5. Research Objectives
The objectives of this research are formulated based on the identified healthcare
problems in the preceding sections. The core objective of this qualitative research
therefore, is
The service performance efficiency of healthcare delivery in the state hospitals
and clinics is sub-standard relative to private hospitals within the same
demographic and geographic region.
To gain insight into the cause-effects of this minimal performance, patients’
dissatisfaction and the waste of resources in Gauteng public healthcare service
sectors.

21 October 2013 5
The following subsidiary objectives stem to accomplish this research intent:
 To indicate the nature of service, patients’ satisfaction (centeredness) and
Performance level of Gauteng healthcare sectors.
 To indicate the extent, influence and the use of e-service and information
access in public healthcare facilities.
 To review the extent of service availability, facility capacity, resource
allocation, utilisation and the efficiency levels of the public healthcare sector.
 To indicate how governance influences healthcare service delivery and
effectively ensuring efficiency of the hospitals.
 To show how the implementation and usage of health policies and strategies
influence service delivery.
 To identify the service gaps existing between the private and the public
healthcare facilities.
 The aim of this research is not to identify individual failures, rather to use the
results as a guide to improve hospital performance in achieving the best
possible healthcare service.
1.6. Limitations and Assumptions of the Research
The following issues and assumptions constrained this study:
 All hospitals in this survey are in the same geographical and demographic
area and the public hospitals obtained equal resource allocations relative to
their levels.
 Due to the complexity and multifactorial nature of efficiency in healthcare,
service quality dimensions and performance assessments tool for quality
improvement in hospitals (PATH) process dominated in the evaluation of
patients’ satisfaction and the efficiency performance of the hospitals.
 Time and resource constraints restricted this research to one primary
healthcare clinic, two public hospitals (one at district level 1 and one regional
hospital level 2) and one private hospital (benchmark) assumed to be on the
same level 2 as the state regional hospital.
 The absence of data on the prices of input limited this research to the
measurement of technical efficiency.
1.7. Conclusion
The dilapidation of services in Gauteng public healthcare sector evident in patients’
dissatisfaction, despite the availability of limited resources prompted this research
study to assess the extent of these performance crises in these healthcare facilities.

Chapter 2: Review of Literature
21 October 2013 6
2.1 Introduction
A healthy nation is a wealthy nation. Health is an important part of a country’s
economy. According to Omachonu and Einspruch (2010:10), healthcare constitutes
work done in the prevention, diagnosis, and the treatment of diseases, injury and
other social impairments. Omachonu and Einspruch (2010:10) attest that health
policies, cultural, political, human resources, information technology, organizational
and other socio-economic conditions prevalent in the area influence access and
utilisation of health, these factors intermingle to affect the service and delivery of
healthcare.
Previous literature on the South African healthcare system exists; however,
information on the comparative performance efficiency of the healthcare system of
Gauteng hospitals is rarely available or non-existent. In 2000, Maseye, Kirigia,
Emrouznejad, Sambo, Mounkaila, Chimfwembe and Okello (2006:475) conducted a
similar research on 155 primary healthcare clinics (PHC) in Kwazulu Natal to
investigate the technical efficiency of the public clinics. In the same report, Zere,
Addison and McIntyre (2000) investigated 86 public hospitals in the Eastern Cape,
Northern Cape and Western Cape for technical efficiency. The conclusion of the
various results of the researchers shows that public hospitals in South Africa are
relatively technically inefficient with a minimal patient satisfaction.
2.2 Health Review
This section highlights the Gauteng demographics, health overviews, health
assessments, existing government strategies, and health policies. Also included in
the review is the South African health status, healthcare expenditure, resources
allocation and other influencing factors of the healthcare service delivery processes.
2.2.1 Demographics
The Gauteng province, according to Statistics SA, contributes 34% of the gross
domestic product (GDP), has an unemployment rate of 25.6 %, with 97% of the 11.9-
million ‘hospicentric’ population are habituated in urban areas (Lehohla, 2006:5). The
report further states that the province considered as the smallest among the
provinces, with three major urban areas namely Pretoria, Johannesburg/Soweto and
the Vanderbijlpark Industrial Complex is bordered by the four (4) provinces of
Limpopo, North West, Free State and Mpumalanga. Among its most important health
institutions are Charlotte Maxeke Johannesburg Academic Hospital, Steve Biko
Academic Hospital and The Medical University of South Africa plus numerous such

21 October 2013 7
health institutions as universities and nursing colleges (Gauteng Department of
Health, 2011:1)
Table 2.1: Gauteng Public Hospitals / Levels
Source: Gauteng Department of Health, 2012:1.
Lehohla (2006:24) and Gauteng Health and Social Development (2011:1) further
remark that the Gauteng statistics constitute twenty (20) community health centres
(CHC) and over 200 private hospitals and clinics. These researchers also indicated
the provisional baseline waiting times in CHC to be 88-200 minutes, accident and
emergency unit for priority patients 2 and 3 (48-180 minutes) and pharmacy (50-120
minutes).
The Gauteng health demographics in table 2.2 indicates a proportional increase in
the rate of disease infections with a greater percentage of the population in the public
sector affected due to the pronounced social variance in this province. Day and Gray
(2010:227) report that adults and children on antiretroviral treatment were on the
increase from 2005, with an increased rate of maternal and infant mortality.

21 October 2013 8
Table 2.2: Demographic Indicators of Gauteng Province (Extract)
Source: Day and Gray, 2010:227.
2.2.2 Gauteng Healthcare Overview
Gauteng health service structure (figure 2.1) allows for efficient communication,
encourages departments and groups within the health unit to work together,
establishing a hierarchy of responsibility that allows the system to grow in a
controlled manner (Gauteng Department of Health and Social Development,
2011:15).
Figure 2.1: Gauteng Provincial Health Services Structure
Source: Gauteng Department of Health and Social Development, 2011:15.

21 October 2013 9
Gauteng healthcare service delivery has the sole aim of providing well-deserved
healthcare services to its stakeholders. The various units of the provincial healthcare
management, information technology, operations, human resources, corporate
services, strategy and policy are distinctively structured to achieve this objective
(Gauteng Department of Health and Social Development, 2011:15). According to
Couper, de Villiers and Sondzaba (2010:120), the major emphasis centres on
primary services of sustainability, free health care services for children under the age
of six and pregnant women, abortion policies, and free access to primary healthcare.
These efforts and accomplishments (table 2.3) notwithstanding, great challenges
persist in the area of rationalization of tertiary Services in the Gauteng health system.
Table 2.3: Past 15 years Accomplishments and Shortcomings of South African
Health
Source: Harrison, 2009:2.
Couper et al. (2010:121) argue that the slow pace to distinguish the academic,
central and regional hospitals in their services exerts pressure on the provincial and
regional hospitals because patients believe that great satisfaction only comes from
hospitals higher in service level. Couper et al. (2010:121) continues that attracting
health professionals constitutes one of the biggest problems in government hospitals,
constrained by a limited budget and improper alignment with the redistribution and
rehabilitation grants, notwithstanding the WHO recommendation (2004).
2.2.3 Health Assessment
The unimpressive health outcome demands a huge emphasis to improve health

21 October 2013 10
System performance. The first quarter 2011 report (table 2.4) of The South Africa
Development Index, published by The South African Institute of Race Relations
(2011:4) on a health status survey of the Gauteng province shows an increment on
HIV infections and infant mortality with a decline in female life expectancy.
Recent figures show that the South African population approximates to 50 million
with increased male life expectancy and a drop in female life expectancy with
immunization and HIV infection rates having increased (Department of Health,
2005:9; Global Health, 2005:3; South African Institute of Race Relations, 2011:4 &
World Health Organisation, 2009:10).
Table 2.0.4 South African Health Review for First Quarter 2011
Source: South African Institute of Race Relations, 2011:4.
A similar result presented by Day and Gray (2011:5) shows that hospital bed density
stands at 2.84 beds /1000 population and HIV/AIDS related deaths have increased.
Day and Gray (2011:7) further remark that among these, Gauteng represented
19.4% of the SA population with HIV/AIDS, lamenting that HIV/AIDS is the largest
single cause of death amounting to 33% of all deaths in the province. Day and Gray
(2010:242) and Harrison (2009:11) agree that there is little detectable change in TB
incidence, and cure. Bradshaw, Pillay-Van Wyk, Laubscher, Nojilana, Groenewald,
Nannan, Metcalf (2010:3) warn that 44% of all premature deaths in Sub-Saharan
Africa come from AIDS/HIV related diseases, infections and parasitic diseases were
prominent in the district and regional level data with adult mortality getting less
attention in areas of policy, resources and monitoring effort (Day & Gray, 2010:230;
Lehohla, 2006:4).
The WHO (2010:9), Department of Health (2005:9) and Global Health (2005:3)

21 October 2013 11
reason with the South African Development index report that South Africans are not
healthy. Overlooking such factors is disastrous; however, tracking number of deaths
(figure 2.2) and births improves the process (Day & Gray, 2010:230; Lehohla,
2006:4).
 Trend in Mortality Rate
Adult mortality gets less attention in areas of policy, resources and monitoring effort
(Day & Gray, 2010:230; Lehohla, 2006:4). These researchers warn that deaths are
on the increase in sub-Saharan Africa because of the HIV pandemic, adding that
44% of all premature deaths come from AIDS, Syphilis, Homicide, Tuberculosis and
related injuries. Day and Gray (2010:230) affirm that certain infections and parasitic
diseases were prominent in the district level data as the main major causes of death.
Figure 2.2: Trends in South African Mortality
Source: Bradshaw et al., 2010:3.
 Historical Overview of TB and HIV/AIDS
TB/HIV related illness is known to be a major cause of death in the country. The
public health sector response to this trend is rather slow. Kautzky and Tollman
(2008:2) contend that HIV/AIDS exerts immense strain on all aspects of the health
system, citing that during Nelson Mandela’s regime, HIV was never a priority; Thabo
Mbeki’s regime was where the leadership oversight progressed to unqualified denial
that led to confusion, programming delays and seriously comprising governmental
authority. Kautzky and Tollman (2008:22) conclude that the aftermath was a
worsening in health indicators, escalating virus transmission and decline in life
expectancy.
The Department of Health (2011:8) in The South African National Health Insurance
(NHI) policy paper reveals that the South African population constitutes 0.7% of the

21 October 2013 12
world population and carries 17% of the entire AIDS infection in the world (23 times
the Global average), with a TB co-infection record of 73% (highest in the world). This
terrific HIV surge, Harrison (2009:20) remarks created an unexpected demand on
anti-retroviral treatment (ART). Negligence or not taking into cognisance of this vital
information immensely affected the service delivery process at the PHC level.
Within these periods of HIV treatment upheaval, much data on patients were lost
especially those not registered or who died after commencement of treatment
(Harrison, 2009:20). The current information when compared to MDG 2015 targets
seems unrealistic to achieve. The infant mortality rate, maternal mortality rate and life
expectancy figures of 2010 are improving at a ‘snail’ speed (Day & Gray, 2010:213).
Day and Gray (2010:242) in a paper titled “Health and Related Indicators in South
Africa” point out that there is little detectable change in TB incidence, and cure,
concuring with figure 2.3 presented by Harrison (2009:11) on the steady increase
rate of TB transmissions.
Lancet (2011:375) estimates there to be 1.37 million incident cases of HIV positive
TB, attributing the causes of these deaths to the complications of multi-drug resistant
(MDR) and extended drug resistant (XDR) viruses. Despite such invigorating actions
as ‘Stop TB Strategy’, intensification of research towards innovation, development
and enforcement of bold health system policies and the establishment of links
between the broader development agenda and its promotion by the government on
this pandemic, no discernible improvement is accomplished. These numbers are
frightening, considering the rate of infection of TB and HIV, life expectancy reduction,
high maternal and infant mortality ratios despite the efforts of the Government and
other healthcare stakeholders in curbing this menace of dreaded burden of diseases
in the country.
The increase on the cure rate evident in the successful completion rate is just a
small-strived effort on the actual burden of diseases with the expectation that by
2014, it will increase to 85%, according to the South African Health Review report
(Day & Gray, 2012:242). The data shows the impact of TB measurement, access
barriers, communication, social mobilization, contact tracing, recording and other
diagnostic tools, which immensely affect the service delivery process.
2.3 Healthcare Strategies and Policies Review
Various policies, statutes and legislations govern healthcare service delivery both
locally and globally. In South Africa, most of these laws fall within the portfolio of the
Department of Health (Pearman, 2011:115). Pearman points out that the national
and provincial healthcare systems replaced the Health Act No 63 of 1977 with Act
No. 61 of 2003, previously assigned to provincial government legislation that gives

21 October 2013 13
the national government a supervisory power to ensure the implementation of the
new law. Section 7(2), section 27 and section 36 of the constitution (referred to as
the Bill of Rights) focuses on fairness (equity), responsiveness, and access to quality
of health meets the demands of the South African health needs.
The WHO (2010:9) regrets that efforts toward health systems improvement to meet
with the millennium Development Goals (MDG) in South Africa is unreasonably slow
especially in addressing the complexity of burden of diseases, access and
affordability and ensuring responsiveness to population health needs. Taking urgent
and strict procedures in observing and following the relevant issues is extremely
important, the WHO advises.
The integration of local and provincial health systems was fraught with unexpected
obstacles. More problematic was the employment of health personnel under a single
authority, the effect of uniform salary schedules and conditions of employment
caused by slower restructuring of local and provincial governments, concerning
comprehensive health service provision (Department of Health, 2005:6), this reform
process becomes an end in itself and not a means to improve health system
performance (Arries & Newman, 2008:3).
According to Marks, Hunter and Alderslade (2011:24), patients’ information and
records either are in files or still not properly documented. Challenges countering
access to patient data, safeguarding patient privacy, safe and effective data sharing,
results in governance system slack (Department of Health, 2005:6). Mbananga,
Madele and Becker (2002:14) contend that electronic transfer of information like
prescriptions from one hospital or service provider to another is not in existence.
Marks et al. (2011:24) and Mbanaga et al. (2002:14) insist that the delay in improper
implementation of hospital information systems negatively affects patient information
transfer within and between hospitals. This affects the delivery of services across the
department, especially in the re-engineering and standardization of patient
administration and related procedures throughout the hospitals, hence, eluding the
information dispersion necessary for performance evaluations and health care audits.
Mbananga et al. (2002:18) and Shih and Schoenbaun (2008:xii) warn that the policy
on decentralization of hospitals, and the slow pace in the governance system may
affect the decision-making due to unavailability of integrated management
information. Shih and Schoenbaun (2008: xii) advise that government as a matter of
urgency shall increase its efforts in establishing care co-ordination networks, care
management services, and after hour coverage and performance.
Lorenzo, Ronquilo, Nodora and Silva (2007:4) highlight another major weakness in
the health system as the workforce’s lack of monitoring and evaluation of information.
Shih and Schoenbaun (2008: xii) reveal that current training programs of health

21 October 2013 14
professionals do not adequately prepare them as a team based for the huge
demand intensive labour healthcare service, these researchers insist that the training
must provide system-based skills and competencies. According to Lorenzo et al.
(2007:11), lack and/or shortage of proper training system, including human resources
and use of proper equipment has affected the actualization of MDG targets, child
survival and health outcomes. Appropriate training and training equipment,
distribution and support of health professionals have a severe implication on the
management as well as technical emphasis on resource management. Lorenzo et al.
(2007:12) and Taylor (2009:1) affirm that low remuneration of health professionals
and a lack of policy guidelines on standardised wage rates affect health outcomes.
According to Day and Gray (2010:311), the survey of PHC facilities conducted in
2003, in 31 health facilities with the focus on patient safety, cleanliness, infection
control, staff attitudes, waiting times and drug supply, found that half of the facilities
were in bad condition because of negligence, lack of maintenance and even
vandalism and theft. Day and Gray (2010:311) further reveal other key aspects
influencing service delivery as insufficient resources, existence of cultural practices
(opposition to clinical immunization, enemas and use of traditional medicine) and
infrastructural problems.
The high value attached by healthcare givers to diagnosis and treatment when the
patient is ill makes delivery costs highly unaffordable and unattainable in the
restoration to full pre-disease health for chronic illnesses. However, proactive care
strategies, which focus on personalized prevention production, early detection,
treatment and disease management creates a healthier population and at a lower
cost (Adams, Baker, Boroch, Knecht, Mounib & Stuart, 2008:14) through the
introduction of a National Health Insurance (NHI).
According to the Department of Health (2011:18), the NHI strategy, rooted in the
South African bill of rights, in adherence to the WHO performance recommendations
is established as an avenue to alleviate the needs and wants of the huge insatiable
demands of the public. Based on the principle of affordability, equity, right to access,
social solidarity, effectiveness, efficiency and appropriateness of care, its major
objective is to procure services, mobilize and control key financial resources in order
to eradicate the weak purchasing power, which is a major limitation of some of the
medical schemes that results in spiral costs. Other achievable targets are to provide
and improve access to quality health services for all South Africans and to achieve
social solidarity and equity through the creation of a single fund (Department of
Health, 2011:18).
There are clear indications that government is failing in all efforts to curb the
inadequacies in human resources, governance, burden of diseases, and excessive

21 October 2013 15
expenditure justified by these causative agents that has resulted in poor healthcare
service outcomes. In lieu of this, government saw the need to transform the health
sector in not only finance, and human resources but to strengthen the plan,
information management, service provision and the total overhaul of management
systems (Department of Health, 2011:6).
2.4 Human Resources
There is a dearth of information in this area for private hospitals. According to the
Department of Health and Social Development (2012:1), in 2010 the medical
workforce was estimated to be 40,000 nurses, 6775 medical practitioners and 5410
medical specialists. The fact is that shortages of nurses and doctors affect health
services adversely, and as such, South Africa’s health crisis will continue to surge.
The growth rate according to The Health Report (2009) considering human resource
health (HRH) showed an annual growth rate of 1.8% (nurses), pharmacist (2.3%) and
medical practitioners (2.5%) (Department of Health & Social Development, 2012:1).
Arries and Newman (2008:4) claim that South African health institutions struggle to
fill more than 60% of existing posts, yet over 4000 vacancies exist for general
practitioners, 32000 for nurses (all provinces) and 31% of other medical positions
remain unfilled nationally partly due to emigration and policy bureaucracies. Over
63% of available general practitioners work in the private sector, which is nearly twice
as many as in the public sector, between 30-50% of South African medical graduates
migrates each year.
The emigration of essential medical staff undermines the cultural point of care
especially in PHC service provision (Kautzky & Tollman, 2008:24). The researchers
point out that, the scarce skills complicated by a decrease in enrolment of nurses in
government institutions, is a consequence of a lack of planning to increase capability
of medical institutions. The WHO (2010:319) suggests that improved retention
increases access to health workers in rural areas. It further recommends financial
incentives, personal and professional support, regulatory mechanisms and focuses
on education as a means to make a reasonable change.
2.5 Health Expenditure
According to Day and Gray (2010:9), the WHO recommends that on the average, a
country should use at least 5% of its GDP on healthcare, but surprisingly South
Africa spends 8.5% of its GDP on health, far exceeding the WHO recommendation,
Nonetheless, the health outcomes remain an illusion. For instance, over 70% of
theatre times at the Charlotte Maxeke Johannesburg Academic Hospital with trauma

21 October 2013 16
cases require a large supply of blood, the cost of which escalates between 15-35%
while the budget only increases at the rate of 5% (Department of Health, 2008:55).
Most of the expenditure on health ( in table 2.5) goes to the district health system.
However, the private sector absorbs 61% of national health expenditure in providing
medical care to approximately nine (9) million people and the rest 40% goes to the
public sector that provides medical care to 41 million (Kautzky & Tollman, 2008:24;
Ngwenya, 2007:164). In a report titled “Healthcare in a Democratic South Africa,” the
Department of Health (2005:2) stated that the reality of dualism in healthcare delivery
persisted with a significant private-for-profit sector alongside the public health sector.
Gauteng residents tend to be hospi-centric, bypassing clinics to either district,
regional or tertiary hospitals, when clinics can conveniently resolve their cases. This
leads to congestion in hospitals and wasteful use of resources when treated at a
higher level (Gauteng Department of Health & Social Development, 2011:32).
Table 2.5 Provincial Health Expenditure (Rands in millions)
Source Gauteng Department of Health, 2009:8.
Before the reversed tax subsidy for private health care in 2006, the state spent more
per head on private health sector delivery than public (Ngwenya, 2007:164), thus
attracted more health professionals to the private sector making the ratio of patients
to health professionals lower in the private sector, (Kautzky & Tollman, 2008:24)
conclude. McAuliffe (2004:2) remarks that the system must respond to people’s
legitimate health expectations based on need and not on the ability to pay; and must
ensure fair financial contribution for the users of the healthcare system.
The Gauteng Department of Health (2009:8) in a paper titled “Integrated Support
Team,” reviewed health overspending and macro-assessment of public systems in
South Africa. After an extensive investigation, it came up with a report that “bloated”

21 October 2013 17
bureaucracy, poor financial management and inadequate monitoring resulted in the
poor value for money spent by the public healthcare sector. Harrison (2009:2) in his
findings listed these shortcomings attributing it to a cause-effect of a lack of
managerial accountability in the attainment of service related targets.
2.6 Healthcare Service Performance
The Department of Health (2005:8) and Msimang (2005:5) agree that South Africa
ranks low in healthcare system performance and that health worker’ training and
supervision are not standardised and comprehensive. The dismal state, according to
the Gauteng Department of Health (2009:3) included inequitable healthcare
spending, poor leadership, accountability and fiscal discipline, limited child advocacy,
poor performance in service delivery and an inability to translate policy to practice.
The Department of Health (2009:9) annual report states that various surveys and
studies conducted on health facilities indicate inadequacies in affordability, access to
facilities and quality of care in the public sector. According to this report, an
assessment of 31 health facilities using the revised core standards (PATH
framework) confirm that the facilities were in a bad condition due to poor
maintenance, vandalism and theft. Over 59% of the province uses public hospitals,
25.3% (Private), while 33.85% never used the nearest facility citing excessive waiting
times, 15.9% non-availability of medicines, 10.8% rude/uncaring staff as the reason.
Reports on higher levels of satisfaction shows that in private healthcare facilities
92.4% of users were very satisfied with the services they received (Department of
Health, 2009:9).
Day & Gray (2010:312) reveals that the NSDA estimated 87.5% (2009) of the public
sector health users to increase to 90% in 2014/15, but highlighted the lack of
affordable and accessible transport, particularly for the continuity of care and
treatment of HIV and other chronic diseases. The report continues with The Human
Science Resource Council’s household survey, which shows a high utilization of
healthcare services of 90%. Those hospitalized for 6-9 days accounted for over 20%
of this number, indicating a failure of the PHC system’s ability to prevent and
adequately manage diseases (Day & Gray, 2010:312).
To achieve better equity to match the MDG 2015 target, Soumya et al. (2009:8)
emphasises the importance of delivering an efficient and effective healthcare system
especially in the three 3 aspects of health service priorities of access, quality and
utilization. Shih & Schoenbaun (2008:1) affirm that several influencing factors affect
these aspects of service delivery process in healthcare system, stating that
information gaps in the paper medical records could cause a lack of care co-
ordination and support. These researchers contend that 17.6 % of hospitalization,

21 October 2013 18
according to the study, resulted in re-admission within 30 days and of those, 75% is
potentially preventable; far fewer hospitals provide a full care transition program.
Medication and reconciliation often proves difficult because of a lack of co-ordination
between the ambulance units and the hospital due to either a scarcity or the non-
existence of electronic medical records (Shih & Schoenbaun, 2008:1).
Most public sector hospitals, Shih and Schoenbaun (2008:4) argue do not have a
system in place to track and deliver appropriate care, and this results in the lack of a
participatory role in achieving improvements in quality initiatives. In addition, the
implementation of an electronic medical record system with disease registries, care
reminders and clinical decision support has not been possible. Statistics show that it
is difficult for 80 per cent of South Africans to get care during the night, weekends or
holidays without going to the emergency room (Shih & Schoenbaun, 2008:4).
2.7 Healthcare Service Satisfaction
In a Statistics SA survey, Lehohla (2006:4) further indicates the usage of healthcare
services; 59% (Public Clinics); 25.3% (Private); 15.7% (Public Hospitals) with 91% of
households using the nearest facility of its kind; the outstanding 8.3% cited other
reasons in not using the facilities. Of this percentage, 33.8% gave reasons such as
excessive waiting times, 15.9% non-availability of medicines and 10.7%
rude/uncaring staff, (Lehohla, 2006:4). Satisfaction levels for private healthcare
facilities were higher (92.4% of users were satisfied with the services received), while
public health care reflected only (54.3%) (Day & Gray, 2010:311).
A common perception since 1994, is that primary healthcare services are grossly
inadequate, a result of an assessment of hospital-based services for four chronic
diseases (diabetes, hypertension, asthma and epilepsy) conducted by Steyn and
Levitt in eight Gauteng hospitals. The report shows that the causes of service
inadequacies in these hospitals included shortage of staff, lack of training, short
consultation times, little patient education in self-care and infrequent use of
management guidelines and standard assessments (Steyn & Levitt, 2005:228).
Arries and Newman (2008:1) reason that the healthcare in South Africa needs a
coherent, transparent, efficient, effective, accountable and responsive vision
transformation. This transformation process of people-centred and result-driven
service characterized by equity, quality, timeous delivery, and a strong code of ethics
rests social change awareness, emphasis on the community’s need for self-
expression as well as environmental, economic and political issues affecting it.
The following narrative gives an insight into the nature of services received in public
healthcare facilities:

21 October 2013 19
“A pregnant woman in a complicated stage of labour was referred to a regional
hospital for child delivery and an ambulance service was called in for the transfer
from a district hospital. When the ambulance team arrived, the nurses were on a
teatime break, as such not mindful of the patient’s critical condition. The ambulance
team waited for an additional 45 minutes while the pregnant woman was in
excruciating labour pain.”
Quality of service is a measure of responsiveness, courtesy, customer orientation,
reliability, confidentiality and care, (Arries & Newman, 2008:2; Fitzsimmons &
Fitzsimmons, 2011:4) that show either positive or negative service perception of a
health provider by a patient (Arries & Newman, 2008:2). Elaborating on the lack of
service commitment and service orientation, The SA Health Act and The SA
Constitution provides legal rights and obligations to practice responsibly, in
accordance with the nurses pledge of service ‘To serve the community with respect
and dignity’, which often remains unfulfilled. (Arries & Newman, 2008:2).
To match these demands, Arries and Newman (2008:2) point out the need to avoid
error in every single procedure especially in filling proper prescriptions, administering
medication, tidying waiting areas, timeliness (promptness in service), answering
questions (responsiveness), and politeness (even if the patient is overbearing,
inconsiderate and downright offensive). Reassuring patients (courtesy) and
friendliness are to be the top most priorities, Arries and Newman (2008:2) concluded.
2.8 Hospitals Efficiency in Gauteng
There is the urgency to assess efficiency and productivity of hospitals given the
theorised deep magnitude of inefficiency, in addition to macro-economic and socio-
demographic realities of this province. However, the dearth of information on hospital
efficiency in the Gauteng province shows limited priority given to it in the provincial
health system. Kirigia et al. (2008:4) investigated the technical efficiency of 155 PHC
in Kwa-zulu Natal, Eastern Cape, Northern Cape and Western Cape, and Maseye et
al. (2006:479) conducted the technical efficiency study of 86 public hospitals. The
results of the analysis found that public hospitals are technically inefficient. According
to Kirigia et al. (2008:2), monitoring the limited resources such as human resources,
pharmaceutical supplies, non-pharmaceutical, clinical technologies and ambulances
helps to improve the quality of health, reduce waste and implement policies geared to
productivity enhancement which facilitates the attraction of more domestic and
external resources into the health sector. The researchers remarked that population
needs are unlimited and insatiable, striving to meet these demands makes efficiency
an inevitable process (Kirigia et al., 2008:2).
Zere (2000:11) and Taylor (2009: 1) reveal that in practice health administrators give
little attention to efficiency, instead focusing on health sector reforms and mobilising

21 October 2013 20
additional resources for healthcare through user fees and other finance modalities,
this results in inflated costs of service. These researchers warn that inflating the cost
of service deteriorates to inefficacy and inequity that denies citizens the opportunities
to realise health improvements at zero cost and this culminates to inefficiency,
making it immoral and unethical. According to Zere (2000:12) and Kirigia et al.
(2008:2), inefficiency emanates from over-staffing, stock wastage, excessive hospital
length of stay, excessive waiting period, and over-prescribing.
Efficiency, as a very important factor in health systems takes cognisance of the
different stakeholders and their needs, wants and expectations resulting in improved
profitability outcomes.
2.9 Gauteng Public and Private Healthcare Service Overlaps
Satisfaction of patients’ values and needs leads to customer loyalty and constant
patronage. This fact contrarily affected the public healthcare facilities. Berger,
Thomas, Vital and Wang (2011:2) and Hassim, Haywood and Berger (2008:164)
predict that private healthcare sector largely run on commercial lines has begun to
take over many tertiary and specialist services, caused by long appointment
schedules to patients by the public hospitals due poor performance of service.
Identifying serious service overlaps existing between the private and public
healthcare sectors, Hassim et al. (2008:164) maintain that the inequalities that exist
in accessing healthcare services is made evident by the excellent services offered in
the private sector. The researchers warn that non-prioritization of this problem
through regulation to end the inequitable and unaffordable distribution of health
services, will perpetuate the suffering of the communities. The tax subventions and
benefits offered to private medical scheme high-income earners are such that the
more expensive the product is, the greater the government subsidy allocated to it.
High-income earners and the middle class prefer to use these benefits in private
hospitals believed to offer a better service, Hassim et al. (2008:164).
Berger et al. (2011:2) attest that government inability to meet the demand of patients
(80%of the population) in areas of the PHC is a concern especially in anti-retroviral
drug rollouts and immunization vaccines. The inability to match demand to service
forces the Gauteng government to contract private healthcare sectors often both in
the utilization of its health facilities and professionals for specialised services. For
instance, private hospitals in Johannesburg offer medical services to the Department
of Correctional Services prison inmates, aggravated by the private sector employing
health professionals and medical expertise originally trained at the state expense.

21 October 2013 21
2.10 Conclusion
The burden of diseases, limited available resources, changing policies, incoherent
information dispersion, managerial incapacity and constant restructuring of
leadership have led to disruptive uncertainties and a lack of focus in healthcare
service delivery (Gauteng Department of Health & Social Development, 2011:46). In
most cases, neither the political leader nor the head of department is a health
professional, resulting in no decision or an inappropriate decision made regarding
health related issues, particularly in health service delivery.
The high mortality and morbidity rate, HIV and TB infection resurgence rates, and the
increased population density constitutes major problems in service delivery. There is
a lack of culture of using information for management purposes. Though the policies
are established, WHO and MDG benchmarks set, there is an unclear understanding
of the resources, skills and capacity requirements for the implementation or the
resource gaps and constraints experienced at the service level. There is a need to
revalidate the concepts and theories that underpins the allocation and utilization of
resources, service delivery, and satisfaction, models of care, capacity planning and
leadership.

Chapter 3: Conceptual Theories and Performance Models
21 October 2013 22
3.1 Introduction
In response to people’s expectations and fair financial contribution and to maintain
the healthy status of the population, there is a need to examine the strategies,
theories, concepts and models of the healthcare systems that could alter the service
performance.
3.2 Healthcare System and Governance Concept
Current health challenges and the deteriorating health inequalities within the province
make governance an utmost priority that ensures proper allocation of resources,
accountability and performance monitoring.
According to Balfour (2007:4), health is not only the absence of disease and infirmity,
but also a complete state of physical, mental and social well-being that involves
promotion, prevention, diagnosis, treatment, and rehabilitation, which must be co-
ordinated in such a way as to achieve a good outcome (Balfour, 2007:4; Omachonu
& Einsprunch, 2010:10). However, the WHO (2010:50) defines a health system as
“an ensemble of all public and private organisations, institutions and resources and
other activities to improve, maintain or restore health. Health systems include both
personal and population services as well as activities that influence the policies and
actions of other sectors to address the social, environmental and economic
determinants of health.”
Marks et al., (2011:19) argue that public health systems do not only include
resources, organisations and services but also are constrained by the boundaries of
the societal activities beyond health operatives. Prominent among the functions of
the health system include stewardship (governance), training and financing.
Governance as shown in figure 3.1 aligns the different efforts to optimise health
gains. The performance of these functions minimizes the gaps between customer’s
expectations and the service delivery (Fitzsimmons & Fitzsimmons, 2011:117).
The taxes and social insurance revenues collected by the government support the
key roles demanded by the public from government in providing good health
systems. Government itself regulates and enforces the operation of health services
aimed at improving health system performance.
Government through its financing mechanism such as budget allocation, rising of
health awareness, taxation, and adoption of specific health standards and regulation
of pharmaceuticals is at the centre stage of meeting the patient’s healthcare service

21 October 2013 23
expectations (Department of Health, 2005:3).
Figure 3.1: Concept of Health System and Public Health Boundaries
Source: Marks et al., 2011:19.
The various consultative councils and monitoring committees (shown in figure 3.2)
from all hospital levels to the hospital management and the community are entrusted
with the resources, responsibilities and protection of the public interest (Ogunefun,
Moyo, Mbatha, Madale & English, 2012:1).
Figure 3.2: Health Monitoring Committees
Source: Gauteng Department of Health, 2003:5.

21 October 2013 24
The monitoring committees through the active participation of the politicians,
managers and medical experts play a stewardship role in ensuring good health as a
human right by acting as an intervention ladder between the government and its
policies, regulators of health norms and standards, monitoring of the system and
bridging the service gap.
The health sector involves a complete transformation of national healthcare, the
delivering system, all relevant institutions coupled in addition to thorough review of
legislation, organizations and institutions related to health. It ensures community
participation in every service decision-making process, the need for teamwork and
affirms that all health practices are in line with international norms and the WHO
recommendations (Department of Health, 2005:1). Community participation is
intermediary or the bridging gap between the health governance policy, legislation
development levels, implementation and practice levels, fully involved at the national
and provincial committees (the national and provincial health councils and the
consultative forums) as well as the district and hospital boards (Department of
Health, 2003:5).
3.3 Hospital Levels and Service Structure
Hospitals in South Africa consist of three levels (figure 3.3), each level implies
different levels of service created primarily for in-patient care (WHO, 2006:8-6),
although outpatient and emergency care does exist (Cullinan, 2006:10).
3.3.1 Primary Healthcare (PHC)
PHC is the first point of service contact in a healthcare system, defined by the
Bailiere Nurses dictionary (2005:318) as “the care given to the individuals in the
community at the first point of contact with the primary healthcare team.”
According to (Cullinan, 2006:12), a hierarchy of health services is established from
the primary level as the first point of call via local clinics and community health
centres at explicitly free service which operates 8 hours a day. This is done to effect
efficient use of scarce resources, with the unsuccessfully treated or more complex
health problems being referred to hospitals. The primary service level, usually run by
nurses is for preventive, promotional, curative and rehabilitation services, with a
particular emphasis on family planning; provision of essential drugs; treatment of
sexually transmitted infections; promotion of food supply and nutrition; care for those
with chronic illnesses; immunizations; mother and childcare and trauma. Major
challenges facing clinics include retention of qualified professional nurses, massive
patient load, irregular or no visits by doctors and the pressure exerted by HIV
antiretroviral treatment and CD-4testing (Cullinan, 2006:12).

21 October 2013 25
Figure 3.3: South African Healthcare Delivery System
Source: WHO, 2006:8-6.

21 October 2013 26
3.3.2 Hospital
Hospital basic definition is paramount in order to access performance efficiency of
healthcare facilities. Cullinan (2006:8) describes hospital as “an organized effort to
provide a specific set of medicinal services, usually physically located in one or
several buildings and related to specialized cure (diagnosis and treatment) and care
(as opposed to the primary care level) with the input of health professionals,
technologies and facilities”.
Ngwenya (2007:164) categorises hospital into two broad components namely private
and public healthcare.
 Private Hospital
According to Ngwenya (2007:164), private hospital is all private health providers
operated by health professionals in private state-of-the-art facilities whose main
funding mechanisms are medical schemes, life and short term insurance, non-
governmental Organisations and out of pocket payments. It is a service-for-profit
institution renowned by its anti-competitive pricing of medicine, and laboratory
services with a relatively good provision of specialist services. This sector is
presumed to be a deterrent cause of high medical scheme premiums. With a never
compromised quality of service and having, 37.3% of medical scheme members’ in
South Africa resident in Gauteng (Ngwenya, 2007:164), there is a differentiating
service delivery factor between the two categories in this province.
Key private health service organisations include the Hospital Association of South
Africa (HASA), which comprises over 183 private groups and independent hospitals
and clinics. The Board of Healthcare Funders (BHF) represents 95% of all medical
schemes and sets tariffs for healthcare services as a guideline to its members and
the National Association for Pharmaceutical Manufacturers (NAPM) (Ngwenya,
2007:172).
 Public Hospital
Ngwenya (2007:164) describes it as health institutions owned by government,
operated in government facilities and managed by health professionals employed by
healthcare institutions to care for the community. It is predominantly a non-fee-for-
service and relatively low fee-for-payment services covering a wide scope of care,
rational healthcare policies and community based staff. Various factors such as
nature and degree of sickness, proximity to patients, and availability of services
determine the governance of the structure level and its operation.
The most common levels available in South Africa as listed by Ngwenya (2006:13)
include:

21 October 2013 27
 District hospitals (Level 1), the first referral hospital level with access to basic
and diagnostic services, therapeutic services, basic laboratory testing,
operating theatres but no intensive care units. Staff comprise of ordinary
general practitioners. It constitutes 64% of the total 388 public hospitals.
According to Department of Health (2002:3), in addition to integration of
clinics’ responsibilities, level one hospitals scope lays is in obstetrics,
geriatrics, pediatrics, surgery, psychiatry and basic family and primary health
care, functioning 24 hours per day, referring patients to regional hospitals as
appropriate. A release on a set of norms and standards called ‘The District
Hospital Service Package for South Africa’ by the Department of Health
(2002:3) spells out the distinct role of district hospitals in supporting PHC, and
as a gateway to more specialist care (Cullinan, 2006:13).
 Classified into two specialized units, a regional hospital (Level 2) is a single
specialist and general service. Notably, Gauteng has more level two hospitals
than level 1 (Cullinan, 2006:13). Both General and specialized level 2
hospitals take referrals from a level 1 hospital and general medical
practitioners serving in the communities. According to Cullinan (2006:16),
general (regional) hospitals (level 2) have at least five permanently staffed
specialists out of the eight core specialties of surgery, medicine, radiology,
pediatrics, obstetrics, gynecology, diagnostics, orthopedics and anesthetics.
The researcher points out that unlike district (level one) hospitals, no norms
and standards, even draft ones, have been developed for this system, yet it is
the most overburdened among all health institutions in South Africa further
effected by the various complicated health problems that culminates service
inefficiency (Culinan, 2006:17).
 National Referrals (Level 3) refer to national, central and national referrals
(tertiary) hospitals (level 3). Cullinan (2006:16) further classifies the different
categories as follows: provincial tertiary hospitals (tertiary 1) and national
referral hospitals (Tertiary 2). This facility constitutes less than 4% of the public
sector hospitals providing specialties such as cardiology related queries,
endocrinology, geriatrics, nuclear medicine; pediatrics sub-specialties, renal
plants, hematology and spinal injury care services.
 Specialized hospitals have a wide range of possible specialist services for
longer chronic in-patient care, constituting 16% of the entire public health
sector and providing extended specialist care for spinal injuries, maternity,
heart, infectious diseases and psychiatric care (Cullinan, 2006:16).

21 October 2013 28
3.4 Healthcare Technology Innovation Concept
This concept is an inevitable accelerant intentionally introduced, applied within a role,
characterised in the form of product, process, service and structure, either disruptive
or non-disruptive (Omachonu & Einspruch, 2010:4), in the form of new services,
technologies and ways of working, regulated by law and utilized by the system
stakeholders in ensuring good health outcomes (Adams et al., 2008: 14). This
concept is designed to perform major healthcare functions that significantly benefit
all, and assists patients in adopting heathier life pattern (Omachonu & Einspruch,
2010:10).
Inappropriate use of these innovations, the researchers warn, may result in death,
disability or permanent discomfort (Omachonu & Einspruch, 2010:9). For instance, a
mistake in injection of spiral anaesthetic during child delivery may cause paralysis of
the patient that may lead to litigation. Hence, there is a need to match the
stakeholders’ expectations for effective and efficient performance.
Non-disruptive sustains and improves an existing idea to solve an inherent problem,
meet stakeholders’ needs, wants and expectations (table 3.1) and accomplishes the
expansion of new opportunities. For instance, a new type of thermometer called the
‘Digital Genius Thermometer’ takes fractions of a second to read unlike the analogue
version. In addition, the use of the Dina map, for blood pressure monitoring has
replaced the old sphygmomanometer.
Disruptive (radical) is either revolutionary, transformational, non-linear that disorders
the old systems and creates new markets, or values while marginalizing old ones and
delivering new values. For instance, the use of telemedicine by doctors to prescribe
drugs or to examine X-rays remotely.
Table 3.1: Stakeholders Needs, Wants and expectations
Source: Omachonu and Einspruch, 2010:9.

21 October 2013 29
Innovation is inevitable in healthcare (Adams et al., 2008: 14) and these include
product, process, service and structural innovation (society and management related
policies) (figure 3.4).
Figure 3.4: Types of Healthcare Innovation
Source: Adams et al., 2008:14.
Omachonu and Einspruch (2010:4) explains the product innovation as what the
customer pays for, while the process innovation typically is the delivery method
where the customer does not pay directly but the process delivers the product or
service, which allows for a significant increase in the value delivered. Structural
innovation usually affects the internal and external infrastructure (facilities) and
creates new business models, for instance, policy and societal innovation,
collaboration, service and business model innovations. Omachonu and Einspruch
(2010:4) further emphasise that innovation not only concerns technology
breakthroughs in medical devices, procedures and treatment, but information
networking that includes security and privacy of patients with information technology
revolutionising things in major ways, mainly with offshore services and drug safety
monitoring on a global scale.
Omachonu and Einspruch (2010:6) add that outsourcing of diagnostic services
(Imaging–X rays, Monograms and Specialist consultations) provides care to patients
in hard -to-reach and under-serviced locations (telemedicine). Drug safety monitoring

21 October 2013 30
on a global scale (Med Watch) involves investigating and reporting on adverse drug
reactions using international databases on drug safety, making use of available high
quality information both for patients and doctors by drawing materials from on-line
textbooks and medical journals, (Omachonu & Einspruch, 2010:6).
3.4.1 Integration of Health Information Systems
Integrated information exchange (figure 3.5) aligns all health systems and incentives
(medical, governance and training) in order to achieve and exceed service
expectations; transforming care delivery through engagement of patients to ensure
safe, easy utilisation, confidentiality and efficient healthcare for the public (Weeks,
2012).
Figure 3.5: Health Information Exchange
Source: Weeks (GSTM Lecture notes, 2012)
A resource intensive information system not necessarily of high-tech is vital both to
service providers on how to achieve the best practice and the individuals on how to
manage their own health (WHO, 2006b: 22).
Most health information function as solo (own rules and formats) and which inhibit the
information from being readily available or globally integrated. Different practitioners
cannot read a patient’s chart in one health institution due to a conflict between
encryption and other software, making it impossible for systems to exchange data
electronically when methods, measures and languages are different (Omachonu &
Einspruch, 2010:6).

21 October 2013 31
Essential knowledge (figure 3.6) ensures what alternative best fits the patient. A lack
of relevant clinical knowledge and patient information forces most health
professionals to rely exclusively on their own experience based on the trial-and-error
method, better known as the expert-or-experience based method. Notably, due to
enhanced technologies, personalized and evidence based medicine increases the
probability of safe and effective health delivery (Adams et al., 2008:4).
Actualising the personalized information age has needed the patient to understand
the shift in the trend of making improved decisions and value care and health care
plan options. This co-produce stage helps patients to optimize their choice of
benefits, creating the next stage in helping patients to bridge the gap between their
health needs and the ability to underwrite these services through holistic healthcare
and financial and retirement plans (Adams et al., 2008:4).
Figure 3.6 How increasing value increases information intensity
Source: Adam et al., 2008:6.
3.4.2 Healthcare Innovation Conceptual Framework
According to Omachonu and Einspruch, (2010:10), every health facility performs five
major functions including prevention, diagnosis, treatment, education, research, and
outreach, for which the cumulative objective (figure 3.7) is to achieve a higher order
of quality, efficiency, costs, safety and reasonable outcomes. To make this possible,
these researchers emphasize that health providers rely on information and
innovations in technology for success, which lies in patient satisfaction. However, not
meeting the needs raises concerns for the patient’s welfare. The processes to
achieve this, require a redefinition of the relationship between the health providers
and the patients (Omachonu and Einspruch, 2010:10).

21 October 2013 32
Figure 3.7: Healthcare Innovation Framework
Source: Omachonu and Einspruch, 2010:10.
Adams et al. (2008:23) using figure 3.8 affirms that these processes involve
transforming value, care delivery and consumer responsibility. The researchers
epitomised that assisting patients to lead heathier lifestyles, and self management in
a co-ordinated care across venues and time, may only be achieved through shared
decisions provided by developed robust information infrastructures. Informed patient
preferences can be achieved by both the patients and health provider focusing on
prediction, early detection, treatment and care.
Figure 3.8: A Win-Win Innovative Transformation

21 October 2013 33
3.5 Performance Assessment Framework
Acceptable health outcomes demand the evaluation of hospitals in terms of
achievement of the goals of patients, the medical personnel, the management team
and society for the satisfaction of all. Shaw (2003:4) and WHO (2003:8) concur in
defining performance (effectiveness) as “the achievement of desired goals (Clinical
and Administrative) based on competencies in application of present knowledge,
available technologies and resources, efficiency in the use of resources with minimal
risk to the patient; satisfaction of the patients, and outstanding health outcomes”.
Wilson (2012:7) describes performance as measuring the effects of medical practices
and techniques on individuals’ health and well-being that culminates in a relationship
between the level of resources invested and the level of results or health
improvement. The hospital performance addresse’ not only the responsiveness to
community needs, commitment to health promotion and service integration in the
overall delivery system but also provides services to all patients, notwithstanding,
physical, cultural, social, demographic and economic barriers.
3.5.1 Outcome Based Performance Assessment Framework
Shaw (2003:4) affirms that assessing performance is a means of defining hospital
activities and comparing that with the original targets (Standard) in order to identify
opportunity for improvement. The influence of technology, service delivery and
finance on such building blocks (figure 3.9) as health workforce, leadership, skill mix,
training, information and work environment propel performance for proper
achievement of notable health system targets in meeting the relevant outcome.
Shaw (2003:4) in his ‘Health Evidence Network’ highlights that the principal methods
of measuring hospital performance must be regulatory inspection, public satisfaction
surveys, third party assessment and statistical indicators. Shaw’s survey theorises
that the effectiveness of measurement of the strategies depends on many variables
such as their purpose, national culture and organizational style, application and the
results usage (Shaw, 2003:4).
The Survey addresses what is valued by patients (experience and satisfaction) and
public, comparing it against explicit standards and third party assessment which
takes into account standards (compliance with international standards), peer review
(self-regulation) and by accreditation programmes (what may be improved rather
than failures). Observations and experimental data based on statistical indicators act
as a guide to standardize management, encourage improvement, and empower
patient choice and to demonstrate a commitment to transparency (Shaw, 2003:4).

21 October 2013 34
Figure 3.9: Performance Framework Showing the Health Outcomes
Source: Soumya et al., 2009:8.
3.5.2 Performance Assessment Tool for quality improvement in Hospitals
Model (PATH)
PATH is the most commonly recommended and accepted health performance model
that incorporates the essential qualities of all healthcare models. PATH is a data
collection tool on performance for hospitals used to compare hospitals with their peer
groups (Veillard, Champagne, Klazinga, Kazandjian, Azah, Guisset, 2005: 3; World
Health Organisation, 2007: 6). It encompasses six dimensions (figure 3.10 and table
3.2), four domains and two transversals. The four domains consist of clinical
effectiveness, efficiency, staff orientation and responsive governance, while safety
and patient-centeredness make up the transversal perspectives (Veillard, et al.,
2005:3; WHO, 2007:6).
 Responsive governance explains the extent the hospital relates to the
community needs; continuity of health services and care irrespective of social,
physical, demographic and cultural inclinations.
 Patient centeredness evaluates the services provided for the needs and
expectations of patients; prompt attention, access to supplier networks,
communication processes and respect for patients in terms of privacy and
confidentiality, dignity and autonomy.
 Clinical effectiveness refers to appropriateness of care and conformity with
healthcare processes by making use of the existing knowledge to achieve
good health outcomes.
 Efficiency is the minimal use of resources such as technologies and
productivity to achieve maximum output (best possible care).

21 October 2013 35
Figure 3.10: PATH Conceptual Model
Source: Veillard. et al., 2005:489; WHO, 2007:6.
 Safety is the evidence of risk reduction demonstrated by the use of structures
in the hospitals, comprised not only the environmental safety but also those of
staff and patients.
 Staff orientation involves the extent to which the staff are suitable for the job;
working in a supportive environment, identification of individual needs, health
promotions, safety initiatives and health status (Veillard et al., 2005:489; WHO,
2007:6).
Table 3.2: Key Hospital Performance Dimensions
Source: WHO, 2007:6.

21 October 2013 36
These key dimensions on performance of the organisations capture the most
important aspects of health. The impact of the operational design of the healthcare
delivery system occupies the primary consideration when evaluating the relationship
between health care organizations and patient; the nature of support, resources and
expectations governs the Clinicians and the hospitals while the nature of the
relationship is based on communication and patient advocacy (figure 3.11). These
triad entities have a unique but interrelated perspective on the needs associated with
health care performance (Cowing, Davino-Ramaya, Ramaya, & Szmerekovsky,
2009:75).
The hospital needs include the operational efficiency, operational effectiveness
(clinical performance measures and risk management) utilised by the clinicians to
deliver quality care in an adequate organisational support which aid in meeting the
patients’ psychosocial needs and perception of service in order to achieve
personalised care and enduring health outcomes.
Figure 3.11: Performance and Quality Measures (Triad Interactions)
Source: Cowing et al., 2009:75.
There is a belief that patients who perceive an encounter with a patient-centred
clinician will show better recovery and better emotional health and fewer diagnostic
tests needs. In addition, patients who comply more with the treatment planned are
satisfied in a well-developed clinician-patient interaction. Furthermore, they are likely
to understand their role in the recovery process, as they adhere with the
recommended treatment, resulting in improved health outcomes (Cowing et al.,
2009:75).

21 October 2013 37
These performance outcome measures (figure 3.12) include technical and objective
guidelines and standards. The functional process (service delivery) is typically a
function of subjective assessments that results in the health outcomes and
performance measures (Cowing et al., 2009:76).
Figure 3.12: Determinants of Performance
Source: Cowing et al., 2009:75.
The public considers hospital performance based on the principles of equity,
effectiveness, efficiency, quality of services and consumer satisfaction. Good
management demands validity, reliability and accuracy of the hospital performance,
compared to the standard norms.
These discussions prompt a contentious question ‘how does the performance of
hospitals compare standards of healthcare activities and its attributes with their
results (value) in service delivery?’
3.6 Healthcare Service Delivery Concept
Service delivery is a dynamic concept that changes as the needs of the stakeholders’
changes but its characteristic nature of matching service with demand to create
satisfaction, accomplished through systematic input-process-outcomes perspective
remains the same (WHO, 2006:8-2).
Grönroos according to Fitzsimmons and Fitzsimmons (2011:4) explains service as
“activity or series of activities of more or less intangible nature that normally, but not
necessarily, take place in interaction between customer and service employees and
/or physical resources or goods and/or systems of the service provider, which are
provided as solutions to customer”
In a slightly different vein, the WHO (2006:9) describes healthcare service delivery as
“the way inputs are combined to allow the delivery of a series of interventions or

21 October 2013 38
health actions. As the main function of the health system, it also performs the
immediate output of the inputs of the other building blocks such as health workforce,
medical products and finances.”
The deterministic nature of the inputs facilitates and manages the process to obtain
the outputs that creates an observable impact (figure 3.13). The inputs influencing
factors such as the rising cost, inaccessibility to timely care, globalization,
consumerism, changing demographics, proliferation of new treatments and
technologies, legislation and policy and changing lifestyles control healthcare change
(Adams et al., 2008:5; Motsoaladi, 2011:11).
Most countries have similar healthcare satisfaction problems but differ in the models
for financing and delivering healthcare, especially in areas with growing resource
challenges, new approaches to promoting health, delivery care and a focus on value
from the entire health system.
Figure 3.13: Systematic View of Service Delivery
Source: WHO, 2006:8-2.
The high value attached by healthcare givers to diagnosis and treatment when the
patient is ill makes delivery costs highly unaffordable and unattainable in the
restoration of full pre-disease health for chronic illnesses, however, proactive care
strategies, focusing on personalized prevention, production, early detection,
treatment and disease management creates a healthier population and at a lower
cost. Different dimensions of value (figure 3.14) exist in health care with the
components of health system values balanced with each other. The disparity existing
in equity and ability to activate healthier lives for citizens, to continuously improve,
innovate and access healthcare is so evident that the healthier population status
demands stringent measures. For instance, a potential diabetic, using a preventive
approach requires a diabetic management strategy, while a complicated diabetic may
require dialysis, amputation or even a kidney transplant.

21 October 2013 39
Figure 3.14: Changing Value Dimensions
Undoubtedly, the health financial burden is heavy on government with a shift to
individuals (citizens) to manage the rising cost of their healthcare and making
decisions of better life style choices (figure 3.15), such as proper diet, adequate
exercises in addition to smoking abstinence.
Figure3.15: Citizens Health Decision Approach
High value care demands the participation of patients in the health decision-making
process and in extreme cases, the value selection is left for the professional to
provide cost evidence of benefits and risks of viable alternatives.
Actualising the personalized information age needs for the patient to understand the
shift in the trend of making improved decisions, value care and health care plan
options. This co-produce stage helps the patient to optimize the choice of benefits,

21 October 2013 40
which creates the next stage of supporting the patient to bridge the gap between
health needs and the ability to underwrite these services through holistic healthcare,
financial and retirement plans.
3.6.1 Service Delivery Models
Hospitals fit into one or more of the several existing service delivery models (tables
3.3 and 3.4). Adams et al. (2008:17) conceptualised the evolution of service delivery
models as community health network, centre of excellence, medical concierge and
price leader, with particular focus on such value dimensions as access to healthcare,
clinic quality, service quality and cost.
Table 3.3: Evolution of Service Delivery Models
Community health networks ensure access optimization across a defined
geographic area while centre of excellence optimizes clinical quality and specific
medical conditions. Medical concierge (special service) focuses on optimization of
the patient experience in an information Technology (IT) enabled administrative
relationship, while price leaders (mostly for the private sector) option ensures the
optimization of productivity and workflow.

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