This is a story of achievement and success in a distant land. The key ingredients of quality improvement are all present—an overarching framework; focused political will by national and field leaders; and a detailed tactical plan for action to improve quality. I am speaking about South Africa—a small country with will and determination on the bottom of the continent—and its national effort to improve the quality of substance use services.
First, some background is necessary. South Africa has a democratically-elected government, in which democracy for all is a concept that has existed for less than two decades. Previously, apartheid was the law, and blacks were systematically and specifically excluded. As a new democracy, the features of democracy are not distant and theoretical, but rather a real part of everyday experience and action, much as they must have been in the U.S. shortly after the American Revolution. The ANA, the party in power, represents the black community and is seeking to define itself and a national strategy going forward.
Within this context, South African national pride is strong and is growing. This year, South Africa hosted the World Cup in Capetown. The country has experienced an afterglow as a result of the games.
Yet, South Africa also has problems that are similar to other African nations. HIV/AIDS has been and remains a very serious and widespread problem. Illicit drug use, including needle-injected drugs, is prevalent, and some areas of the country are experiencing a surge in methamphetamine use. Broad-spread concern exists regarding these problems. Within this complex context, the quality improvement initiative is taking shape.
Now, some details on the elements that make this initiative very notable:
National Performance Measurement Framework. The Office of the Presidency has embraced national strategic planning and national program performance assessment. The philosophy and rationale are very straightforward: A democratic society requires national program performance assessment to assure that the government is meeting the needs of its citizens in an effective manner.
Of great interest, the national program performance assessment framework encompasses two key components: accountable practices and measurable outputs. This clearly suggests that quality improvement must include the introduction of better practices, together with a measurement strategy for outcomes. The fact that it is national policy in South Africa is remarkable. Clearly, we in the U.S. could learn from this model.
National Chemical Dependency Plan. Each half decade, a national Chemical Dependency Council is required to update and submit to the Parliament a five-year plan for addressing addiction throughout the country. This plan can focus on the adoption of accountable practices and measurable outputs. Inclusion of specific goals in the plan increases the likelihood that related programs and initiatives will be funded. The current plan is slated to be revamped in 2011. The National Chemical Dependency Plan is a key enabler of the National Performance Measurement Framework.
Service Quality Measurement Project. For the past 18 months, a national project has been underway to measure the key dimensions of service quality for addiction care. These dimensions are Access, Equity, Quality, Efficiency, and Effectiveness. Each domain includes measures of client perception of care, as well as administrative measures. Ultimately, the goal is to seek national adoption of these core measures, so that both clients and organizations can benchmark their progress. The project is managed by staff from the Medical Research Council, with oversight by a National Advisory Group.
Currently, measures are being pretested by facilities and clients in the Western Cape region. The Department of Social Development in the region has been instrumental in facilitating the pretest work and in providing related funding. Initial funding for the project came from a Centers for Disease Control cooperative agreement with the Medical Research Council as part of a major HIV/AIDS initiative. A number of South African private sector foundations have expressed interest in co-funding the national implementation.
What makes this South African project so exciting is that all key ingredients of success are present: a national framework, an enabling plan, and a clear measurement strategy. Very rarely, if ever, are all three actually available contemporaneously. Our hats are off to the South African Medical Research Council, the National Chemical Dependency Board, and the Office of the Presidency for undertaking this groundbreaking initiative.
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