Recently I met with the management of a health department as part of my work in the healthcare field. I arrived early at the venue located in a large hospital and as the meeting also commenced later than scheduled, I had time to walk around the hospital. I encountered various staff members and patients and was cordially greeted although none asked whether they could assist me or what I was doing in the hospital. What was striking was the dilapidated state of many areas of the facility.
Paint peeled from the walls and there were signs of water damage to the ceilings in various places. A pane of glass was missing in a window opening the corridor to the elements and at another missing glass had been covered with a blue plastic bag, while tattered blinds were visible along the windows of one floor of the building. A blackened plug on a wall showed signs of having short-circuited and in one area dusty broken beds were stacked along a wall indicating they had been there for some time. Windows were dirty, splattered with bird droppings, weeds were growing in blocked gutters and the water trapped in the gutters provided drinking troughs for the numerous pigeons that nested on ledges and unused balconies. Through windows I could see various areas, presumably used by staff and patients, littered with refuse. In places concrete had crumbled revealing rusting reinforcing which in time would presumably threaten the structural integrity of the structure. On a positive note I did pass staff cleaning and polishing the passage floors.
I returned to the meeting venue somewhat depressed by what I had seen. During the meeting managers described actions taken and strategies adopted to improve and ensure the quality of healthcare for patients managed at health facilities in the province. It was mentioned in passing that contractors were in fact on site at the hospital where the meeting was located undertaking various infrastructure projects. The shortfall in real terms of budget allocations was lamented by management and it was raised that without adequate budget allocations the delivery of quality healthcare could not be assured. The fact that health budgets in South Africa are decreasing in real terms due to pressures on the national fiscus is a reality and without doubt this has had, and will have in the future, an impact on the quantum of healthcare that can be delivered to the South African public. But was what I had witnessed before the meeting commenced solely due to financial constraints?
After the meeting while awaiting the arrival of transport to the local airport to return home, I stood outside the entrance of the hospital emergency centre and again neglect of this area was apparent. Litter was strewn everywhere along the areas where patients were moving in and out of the facility while uneven paving made it difficult for an elderly woman to walk leaving the hospital with the aid of crutches. On driving out of the hospital, I noted, what I had failed to observe on my arrival, that the security booms at the hospital entrance were inoperative and that the guard house was occupied by a number of people apparently busy on their cellphones. As a result anyone could enter or leave the hospital at will.
While quality healthcare could and probably is delivered in areas of this hospital, the impression that I gained from my visit was one of neglect. My mood was not lifted as my driver avoided the potholes and negotiated the somewhat chaotic traffic past piles of refuse dumped alongside the road back to the airport. I wondered what has gone wrong with the country in which I live? The driver of the shuttle had earlier told me that he had burst two tires in potholes that were invisible when it rained. Could it be that this is all due to a lack of funding or the consequence of the “nine wasted years” of State Capture? In the hospital in which I had spent the better part of a day, without a significant injection of funding, could the situation have been better? Had the managers with whom I had spent the day recently walked through the areas that I had earlier in the day and had they seen what I had seen?
During my terms heading provincial health departments, I placed great stead on arriving at health facilities unheralded to experience what patients were experiencing before any preparations were made for the visit of a senior manager. I encouraged managers to regularly leave their offices and walk around the facilities for which they were responsible and address the seemingly less important issues such as dirty windows and floors, litter, leaking taps and unhygienic toilets amongst others. I questioned managers on the value of hours spent in boardrooms when their facilities would have benefited from time spent at the forefront of service delivery. It was strikingly apparent when I visited facilities where managers were hands-on and greeted staff by name how much better was when the contrary was the case. I recall on one occasion walking through a facility with the senior manager, who had been in that position for several years, when a staff member asked me who he was. The state of that facility reflected his lack of involvement in the day-to-day activities.
Returning to state of the hospital that I recently visited, while I am certain that additional funds would address many of the challenges, however, without additional funding but greater hands-on management, focusing minor maintenance and repairs I am certain that the appearance of the hospital could be very different. Even casual employment of people in an environment of high unemployment to collect litter would have changed the appearance of neglect. Ensuring that staff do not sit idle in the guardhouse at the entrance of the hospital would not only increase the safety of patients and staff but also improve the public perception of the hospital. Similarly, the chaotic traffic which is a safety risk, potholes and dumped garbage surrounding the hospital are a safety and health risk that should be addressed by a municipality that focused on its basic mandate.
While the quality of healthcare narrowly defined is the degree to which healthcare increases the likelihood of the desired outcome, the quality of the service as perceived by those who enter a healthcare facility may depend on very different factors. The environment in which healthcare is delivered inevitably impacts on both the perception of the patient of the health facility itself but also the perception of the staff who work in that facility. It could be asked if those responsible for the operation of a health facility fail to care for the facility itself, do they then care about the quality of the service delivered within it?
My conclusion from my recent visit and indeed what I have seen elsewhere during the last few years is that while additional funding is indeed required by the public healthcare sector, much can be achieved by addressing what some may regard as trivial issues. I firmly believe that both staff and patient morale would be boosted by a clean well maintained hospital which in the longer term will promote quality healthcare and improved health outcomes. To answer the question in the title of this post, quality does not depend on money alone but rather the more effective management of what is available by people who care.
