National Health Minister, Dr Aaron Motsaoledi Motsaoledi, had to step in to save Gauteng's ailing academic hospitals.
The crisis of mismanagement, poor planning and endemic corruption that has long compromised and even prevented healthcare delivery at Johannesburg’s top tertiary hospitals is being tackled via a national pilot scheme giving power and influence back to clinicians and hospital managers.
Aimed at eventually correcting on-going dysfunction and often-woeful healthcare delivery at tertiary hospitals countrywide, the embattled Gauteng Health Department’s pilot turnaround strategy will be facilitated by the new vice chancellor of the University of the Witwatersrand, Professor Adam Habib. He was hand-picked by a deeply concerned national health minister, Dr Aaron Motsoaledi, who has instructed Gauteng’s warring parties (the hospital clinical leadership, provincial MEC, Hope Papo and Gauteng Premier, Nomvula Mokonyane), to ‘work together to clean up’. The province’s tertiary hospitals have lurched from one crisis to another, previous turnaround strategies hardly made an impact as doctors fought in vain for vital life-saving equipment and/or its repair and maintenance, basic drugs and consumables and sufficient human resources to treat patients — with potentially incendiary disputes such as that over Remuneration for Work Outside the Public Sector (RWOPS) souring relationships even further and leading to accelerated consultant resignations.
In recent years, Gauteng’s tertiary hospital doctors have blamed ‘turnstile’ Health MECs, politically responsible only to their provincial premier, poorly qualified hospital CEOs financially in ransom to the infamously bureaucratic Gauteng Shared Service Centre (GSSC) (which is responsible for all departments’ procurement and payment), and major financial mismanagement by the province (e.g. the 2009/10 Auditor General’s disclaimer after being unable to verify the accuracy and authenticity of R19 billion in transactions). The lack of clear and transparent financial systems, (as required by the Public Finance Management Act), generally, makes it easier to disguise endemic corruption, theft and waste – with much of the wastage blamed by all parties Leadership interviewed on legitimate or semi-legitimate ‘middle-men’ who push up prices or actually steal from hospital consignments, including food destined for patients.
Professor Yasmien Jeenah, clinical head of psychiatry and chief of the medical/clinical advisory committee at Chris Hani/Baragwanath Hospital (where she has worked for 13 years), cited the lack of procurement as the biggest headache. “Medication and lots of essential equipment, it’s not just major equipment but basic things like syringes and needles, bandages and food. We serve socio-economically compromised people. They ask me how they can take their medication at home when there’s no food on the table — but how about when they’re sick in hospital and we can’t provide them with food? Some drugs actually make you hungry. I have never seen things as bad — staff morale has certainly never been worse,” she said.
Jeenah diplomatically described senior management as ”having patches of competency”. However she believed the new intervention, the first directly led and involving Wits University and the top national health leadership (National Health Minister, Dr Aaron Motsoaledi and Dr Terence Carter, Deputy Director-General: Hospitals Tertiary Service and Workforce Management), is “great, and well overdue”. She added; “It cannot be an ‘us and them’ scenario, everyone must truly buy-in.”
Concurring was Professor Martin Smith, chief of surgery at Chris Hani/Baragwanath (where he has worked for 12 years) and new head of surgery at the Wits Medical School. He said at least two features distinguished this ‘turnaround’ from previous failures, which left clinicians highly cynical. “Firstly, Wits comes out very strongly in support of its medical staff, acknowledging the threats to its mandate of training and research and that it cannot be silent on service failure.
“Secondly, provincial government has had to very quickly come up with some model of management that addresses our concerns, not just the current focus on procurement of drugs and equipment but human resources and a whole host of other currently unworkable systems — so this is quite exciting,” Smith told Leadership.
Equating service platform dysfunction with teaching platform dysfunction, he said clinicians and hospital CEOs would in future be allowed to take more responsibility for the environment they worked in. However, he warned strongly that managers would “need to allow them to take that space” (referring to what would amount to a major change in operational culture).
Professors Habib and Mac Lukhele, Head of the School of Clinical Medicine at Wits, confirmed that all parties had signed a ‘developmental accord,’ that included the following immediate actions:
A full 70% of essential stock previously procured via the GSCC will be delivered directly from service providers to the four tertiary hospitals.
All managers and clinicians will be fully briefed by Dr Terence Carter, so that there could be no misunderstanding of what the new systems were. Clinicians will have unprecedented input into the budgets and procurement processes that directly affect them — and they will monitor progress.
Hospital CEOs will have ring-fenced budgets that empower them to set realistic ceilings on major equipment procurement (In mid-2011 it was set at R25 000 by a province desperately trying to manage a runaway budget).
There will be a minimum of three months’ worth of stock of all vital equipment and consumables, (now referred to as non-negotiable stock items), with relevant managers held directly responsible for compliance. All stock, from drugs and needles to equipment, plus maintenance, will be tracked at national level by a newly-installed IT system, (already in place and being test-run).
Smith said that those on-site managers who showed they could manage their cheque books would be allowed to do so (instead of hospital budgets being micro-managed by an official in a remote provincial office).
Both he and Lukhele highlighted the systemic problem of ‘middle-men’ siphoning billions out of the provincial health procurement and maintenance budget, either through unethical practices (The SA Medical Journal reported on allegations of one company delivering hospital food consignments to commercial food outlets in Soweto), or simply adding cost to the end consumer price — sometimes higher than in the private health sector. Smith said a similar R10 million consultant-run intervention in his surgery department between 2003 and 2009 “made it a much happier place to work,” but was shut down after some acrimony with junior managers who seemed to perceive it as a threat to their power. “We simply went to unbelievable dysfunction in a very short time, so I can see why there’s cynicism out there. However this has a real chance of success if all parties come to the table. I have not seen an offering with as much value as this one,” Smith added.
Habib told Leadership that hospital managers and Dr Carter would run the new pilot programme. His job would be to facilitate “a pragmatic, transcendent conversation to address these challenges”, while acting as a channel to the minister if deadlock was reached on implementing any part of the new system. He conceded there was “significant bad blood” between the clinicians, management and the province, with clinicians so frustrated that they have even considered legal action recently. “There are already people saying it is not working, but I will not let them use appeal structures if they have not used (the new) internal ones first! We have to make it work. I am not the judge, the minister is. I’m merely the conduit to him.”
Promising to crack down mercilessly both on clinicians taking advantage of systemic dysfunction to enrich themselves via RWOPS-abuse and on corrupt outside service providers, Habib said; “If you catch a crook you throw the book at them. Throwing a couple of them in jail will have a far bigger impact than crossing the i’s and dotting the t’s. Writing policies never resolves corruption.”
He said he had told the clinicians that he would not defend anyone in violation of their professional ethics; “In fact, I told them I would work with government to smoke them out and I wanted them to help me. That will give me the legitimacy I need to defend them against bureaucratic madness and give them what they need to create an enabling environment. So often it is a dialogue of the deaf, with government talking about accountability and academics talking about academic freedom. Frankly I believe in both. I will defend academic freedom, but not the freedom to protect inherited privilege. We need to be accountable to the patient — we cannot wish the poor away. We can be responsible to the rich and powerful in our society for their skills-set while building a new nation and addressing the historical disparities of our past. They are not mutually exclusive.”
Lukhele said clinicians and managers had to start talking to each other instead of “across one another”. Unlike higher education, health management was a provincial competence where national government provided strategic direction. Health budgets were managed at provincial level with no ring-fencing of funds, making the current federal system clumsy and difficult to manage. Ironically, as in the recent Limpopo medicine stock-outs debacle, the national health minister shouldered the blame, “which is something that needs looking at”. The new Gauteng tertiary health intervention was “busy setting up processes, system implementation and time frames”.
“There has been plenty of walk-arounds and working committees set up, but some of the changes are already concrete and will impact immediately,” he added. Smith bottom-lined the hopes and aspirations of many of his colleagues: “This is the first time I have seen something on the table that I think is workable. If we cannot get this right, I do not know what the solution is for healthcare in this province,” he says.
Lukhele could legitimately add (given that it is a national pilot project), “and the entire country”.