Offering the latest news in health care quality and safety, the ISQua blog also features guest posts from the best and brightest in the industry.

By Anja Smith, Carmen Christian, Dumisani Hompashe, Ulf G. Gerdtham and Ronelle Burger Friday. Jun 12, 2020

Who’s last in the healthcare queue? Evidence from mystery patient visits and household surveys Featured

Who’s last in the healthcare queue? Evidence from mystery patient visits and household surveys


Anja Smith1, Carmen Christian2, Dumisani Hompashe1,3, Ulf G. Gerdtham4 and Ronelle Burger1

1 Economics Department, Stellenbosch University, Stellenbosch, South Africa

2 Economics Department, University of the Western Cape, Bellville, South Africa

3 Economics Department, University of Fort Hare, Alice, South Africa

4 Department of Clinical Sciences, Lund University, Lund, Sweden


South Africa has one of the highest inequality levels in the world and an extremely polarised healthcare system. On the one end, there exists a seemingly high-functioning, expensive private healthcare system serving approximately 16% of the population with hospital services, and up to a third of the population with out-patient services. On the other hand, there is a mostly free-of-charge public healthcare system with a wide delivery footprint that runs the largest anti-retroviral treatment (ART) programme in the world. This part of the system is, however, also known for complaints about long waiting times, rude staff and frequent drug-stockouts.


Given the racial composition of South Africa and our apartheid history which means that income is highly correlated with race, most users of the public system are black Africans1. We know from many international studies and an increasingly urgent global discussion that health outcomes for black people are typically worse than for white people, not only in South Africa1 but also other countries2. All healthcare provision should be scrutinised to ensure that race is not a determining factor in whether people have access to care. And once they have access, race should not influence the quality of care provided.


We do not know much about inequality of healthcare access according to quality of care in South Africa. We have very little comparative clinical quality data available for the two systems. However, household survey data shows big disparities between the two systems. There is a large divide in reported satisfaction levels between users of the public and private systems. From the one dataset we have available on comparative quality of hospitals in the two systems, we know there is a large gap between the quality scores of public and private hospitals3.


There is a scarcity of data on clinical quality in the public primary healthcare system, the part of the healthcare system used by most South Africans, mainly black Africans, on a regular basis. Process quality measures, as captured by measurement of protocol adherence during three types of primary healthcare visits can provide a window into clinical quality of care. We measured quality in the South African public primary healthcare sector for hypertension4, TB5 and contraception through standardised or mystery patient visits, after obtaining ethical clearance for this research.


Mystery patients are community members who present as patients and provide information on their health condition to healthcare workers according to a standardised script. This means that during these visits, healthcare workers are provided with exactly the same information by all mystery patients for a certain clinical area. Given clear clinical protocols, the same type of care or treatment should be provided during all visits of the same type.


The mystery patients visited 39 urban public PHC facilities in two provinces of South Africa between July and December 2016. Three quarters of visits were conducted by black mystery patients and the remaining quarter by patients of mixed ethnicity. This allowed us to collect data on the variation, among other things, in access to quality care by the socio-economic status (SES) of both the feeder community of a facility and the SPs themselves, as well as variation in quality of care by the mystery patients’ race.


We found that the overall quality of care as measured relative to existing protocols and guidelines was low across all clinical areas. In our study there was no clear counterfactual for the private sector so we do not know what quality would have been like there. Opportunities for HIV testing, hypertension progression and pregnancy prevention were missed across a high proportion of mystery patient visits. We could not find clear, consistent evidence that quality of care varied in terms of the race or socio-economic status of mystery patients, or according to the socio-economic status of the clinics’ feeder community. It would appear that public sector healthcare workers generally treated patients the same way in terms of clinical quality of care, irrespective of their easily observable characteristics. But this requires further interrogation and research.


We found tentative evidence that the mystery patients who use private healthcare in their everyday lives reported stricter on the quality of care experienced. This made us wonder whether patient expectations drove their stricter evaluation of care in the public sector. It could mean that educating patients about what they can and should expect from their healthcare providers, creating more assertive patients, may be one way of increasing the quality of care in both the public and private sectors.


Even though the preliminary findings of the mystery patient study do not allude to racial discrimination by healthcare workers in the public sector, more research and interrogation is needed to confirm this. What we are more certain about, however, is that the overall quality of care is low across the three clinical areas as measured in South Africa’s public health sector. We know that the public health sector provides care mainly to black Africans. This inevitably feeds into poorer health outcomes for the most vulnerable population group in South Africa, who still appear to remain last in the healthcare queue.



1.           STATS SA. Statistical Release PO318. General Household Survey 2018 (2018).

2.           Kmietowicz, Z. NEWS NHS launches Race and Health Observatory after BMJ ’ s call to end inequalities. 2191, 32051166 (2020).

3.           Ranchod, S. et al. South Africa’s hospital sector: old divisions and new developments. in South African Health Review 2017 (eds. Padarath, A. & Barron, P.) (2017).

4.           Burger, R. et al. Use of simulated patients to assess hypertension case management at public healthcare facilities in South Africa. J. Hypertens. 38, 362–367 (2020).

5.           Christian, C. S., Gerdtham, U. G., Hompashe, D., Smith, A. & Burger, R. Measuring quality gaps in TB screening in South Africa using standardised patient analysis. Int. J. Environ. Res. Public Health 15, (2018).


Sign Up for our newsletter and receive a monthly digest of news!

Become A Member Today

We all have two vocations in health care – to do our job and to continually improve