I have just finished reading “Zen and the Art of Motorcycle Maintenance” for, I think, the third or fourth time. The book, subtitled, “An Inquiry into Values”, has little to do the motorcycle maintenance other than in an allegorical sense but rather explores the journey of the author Robert Pirsig in pursuit of understanding the meaning of “Quality” against the background of a two week motorcycle trip across America from Minneapolis to San Francisco. The author of this unique book and best seller over the last forty years was committed to a mental institution earlier in his life, probably with a form of catatonic schizophrenia and subjected to electro-convulsive therapy (ECT), a therapy not as widely utilised today as then, which partially obliterated his past memories. The book contains a dialogue between his past and present self on the issue of quality as seen partly through the lens of Zen Buddhism. It is a difficult book to read, one that many fail to finish, but one that reveals something new each time that I have read it.
I was prompted to read the book again after reflecting that as a country we are seeking to provide “Quality” healthcare for all the people of this country and I began myself to question of the meaning of word “Quality” in this context?
“Quality” is a term that has entertained philosophers since the time of Aristotle and Plato and continues to do so to this day. Pirsig in his book suggests that Quality on one level is recognised by the observer as an inherent emotional characteristic that is felt but on another technological level is a measurable characteristic according to certain defined criteria. “Quality” as a word in this context generally refers to attributable characteristics of an object or entity reflecting a high standard or excellence. However, the exact characteristics that reflect quality may differ between people and different sectors.
I was reminded on reading the book that as a young undergraduate medical student in the 1970’s, I had watched patients in a ward at a psychiatric hospital suffering from various mental disorders lying in a row of hospital beds being subjected, as was Robert Pirsig, one after the other, to ECT without an anaesthetic resulting in a generalised convulsion in each case. At the time the experience, which left me distressed and disturbed, was regarded as acceptable and effective, possibly even quality healthcare, whereas today such a practice in the manner it was done would be frowned upon. On an emotional level I was certain what I had witnessed was not quality although at the time I was unable to form an opinion at a technological level as to the quality of the therapy.
The World Health Organisation (WHO) defines quality in terms of healthcare as “the extent to which the health care services provided to individuals and patient populations improve desired health outcomes”. The characteristics that describe quality health care are listed by the WHO as “safety, effectiveness, timeliness, efficiency, equity and being people-centred”. Using the WHO definition, the ECT that I witnessed as a medical student may have met some of the WHO criteria listed above but certainly not my emotional assessment of what I experienced.
Patients admitted to a private hospital may have an interpretation and expectation of quality that differs significantly from those admitted to a public hospital. Whereas the clinical outcome of the hospitalisation could be similar the experience of quality may be vastly different. Prejudices and expectations will colour their experience and perceptions of quality.
Why do I think that a discussion of “Quality” is important?
Measured against the six WHO criteria listed above and indeed the experience of people, the South African health sector overall, despite islands of excellence and quality, in the eyes of many currently falls short with respect to quality. It could be argued that in the public sector this is solely a resource issue and that if adequately funded the challenges to quality would be resolved. However, the public health sector in this country reflects the broader challenges facing the country with limitations in leadership, management capacity and systems hampering the delivery of quality healthcare that will not be addressed by an increase of funding alone. In contrast, the Health Market Inquiry Report (2019) revealed that the private health sector operating under free market principles, despite being generally profitable and perceived by many as quality, would similarly not meet all of the WHO criteria for quality healthcare.
Given the burden of disease, despite the ongoing advances in technology, the overall ability to provide health care will in all likelihood always be less than the need however it is defined. The question then arises how the issue of quality can be addressed if the resources available to do so appear to be lacking? A utilitarian approach to decision making indicates that an action is justified if it produces more “good” or is of greater benefit to the majority than any alternative action. This provides a basis for the consideration of the limitation of healthcare in certain areas when necessitated by a resource constrained environment. This limitation implies that potentially beneficial treatment may be denied to some for the benefit of others. Currently, this reality applies both in the public health sector where such decisions are taken at a policy and clinical level and in the private sector when either medical insurance or personal funds are exhausted and preclude further medical treatment. If decisions are taken in this manner is it still possible to provide quality healthcare for all?
Can the concept of quality of healthcare be married with the need to adopt a more utilitarian approach to the utilisation of a scarce resource and be acceptable to all? It seems to me that despite a restriction of resources available for healthcare, the concept of quality nevertheless remains crucial and valid. Management, administration, systems, staff, practices and protocols all must contribute to ensure that within the resources available quality and excellence prevail. Clearly within these parameters there is no room for fraud, wastage, mismanagement and corruption as each would be contrary to the philosophy of quality and excellence. If this were achieved, then even if there is a need to limit certain therapies and procedures it could be possible to achieve the best quality healthcare possible for the population as a whole. I believe that a vision for the future health system in South Africa that provides quality health care for all South Africans will only become a reality if “Quality” is the guiding principle.
In meeting the requirements of “Quality”, as Robert Pirsig reasoned, healthcare must address these requirements on both an emotional and technological level. For this reason, it is essential that the meaning, importance and implications of “Quality” are understood as if not, “Quality” is doomed to remain the Holy Grail of healthcare … often sought but never found.
