A struggling behemoth hamstrung by bureaucracy and underfunding is how doctors at Chris Hani Baragwanath describe the country’s largest healthcare facility.
Last week photographs of babies in a cardboard box at Bara prompted the national and Gauteng departments of health to announce the appointment of a surgical strike management team to look at ways of improving the running of the hospital. This is the second time in a few years that a management team has been sent in — a situation one professor compared to giving painkillers to a patient for a headache while ignoring the fact he has meningitis.
Healthcare experts inside and outside Bara say many problems are the result of the Gauteng department of health’s failure to provide sufficient management and financial support, and to ensure other healthcare facilities support the hospital.
Bara has a budget of R1,1-billion, yet management has relatively little authority over staff or budgets. ‘The CEO can’t take money from the telephone budget to add to the equipment budget, he has to manage within the line items,†says a doctor. Top management at Bara, which has a catchment population of about 3,5-million people, earn roughly the same as chartered accountants with two years’ experience, according to one estimate.
As an academic hospital Bara is supposed to be the facility of last resort, with secondary and primary healthcare facilities accommodating less complicated cases. Yet doctors say that upgrades promised for community facilities have not materialised.
‘When clinics aren’t open 24/7, when they run out of basic medicines, when the clinic doesn’t even have paracetamol, then patients bypass them and come to Bara,†says a doctor.
Professor Rudo Mathivha, director of the intensive care unit (ICU) and chairperson of the medical advisory committee at Bara, says other academic hospitals, including the Johannesburg Hospital, have devolved lower level services to other institutions. ‘We haven’t done that, the community has nowhere else to go.â€
Describing herself as one of ‘Bara’s boeties†— staff who love the institution and stay — Mathivha says: ‘I’m highly trained, but I feel the system is trying to force me to practise substandard medicine.â€
There are 26 beds in the ICU, less than 1% of inpatient beds compared with a minimum of 8% required. ICU treats between 3 000 and 3 500 people out of the 4 500 who are referred annually. ‘We have people on lifeÂsupport machines in general wards. But we don’t have enough nurses,†says Mathivha.
‘I am very angry. I have to fight for consumables to be used on patients, I can’t get equipment procured on time. I just got a message that ICU, anaesthesia and radiology are allocated R500 000 for equipment. One respirator is R300 000. Anaesthesia machines are close to that.â€
Mathivha says that for 18 months Bara had not heard anything from the province about equipment requests. Equipment at Bara is old — a 2001/02 audit found that almost half of the R350-million of equipment in the hospital had been condemned.
As well as functioning as a community hospital, Bara is also a teaching facility and requires physical and human resources to provide research and training as well as patient care. Overstretched senior doctors mean less tuition for trainees.
Professor Max Price, former dean of health sciences at Wits, says one solution would be to give Bara more autonomy, in a similar way to the South African Revenue Service (Sars). Giving management greater ability to make decisions on budgets and to be able to hire outside of government, set salary scales and hire and fire staff more easily might, he suggests, have the same reinvigorating effect on Bara as it did on Sars.
A pilot study along these lines is struggling into existence in the department of surgery at Bara, with the support of Cosatu’s research arm, Naledi. Head of surgery Professor Martin Smith says management has been given some autonomy over budgets and services. While there has been institutional resistance, support of the chief executive has seen the pilot study ring-fenced from the rest of the hospital and it appears to be benefiting staff and patients.
‘I’ve worked at Bara for too long, the systems inherently won’t work. We think we can identify some of the deficiencies and, given the opportunity to complete the pilot, we could create a system that will work not only at Bara but all hospitals,†says Smith.
The national department of health, the Gauteng department of health, and Bara CEO Arthur Manning did not responded to requests for comment from the Mail & Guardian by the time of going to press.