Water, power cuts and neglect are taking their toll on SA’s top hospitals

The fire broke out in mid-April. Only now is a phased re-opening of the hospital being undertaken.
Image: Sharon Seretlo/Gallo Images via Getty Images

A fire at one of the biggest public hospitals in Johannesburg, the Charlotte Maxeke Johannesburg Academic Hospital, and the delay in reopening the facility has brought infrastructural issues into sharp focus. The fire broke out in mid-April. Only now is a phased re-opening of the hospital being undertaken.

Reopening was delayed due to fire safety issues. A host of compliance measures weren’t in place. These included fire hydrants without a water supply, fire hydrants without correct couplings, non-functional fire doors and a lack of emergency lighting in the stairwells. These deficiencies had been longstanding.

I am extremely familiar with conditions on the ground in hospitals in the area. I interact daily with doctors and students in the different academic hospitals on the circuit of the University of the Witwatersrand. These include the Charlotte Maxeke Johannesburg Academic Hospital, Chris Hani Baragwanath Academic Hospital, Helen Joseph Hospital and Rahima Moosa Mother and Child Hospital. I also visit different institutions in the region.

I completed both my undergraduate and postgraduate training at these hospitals and worked for more than 30 years in the neonatal-paediatric intensive care unit and neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital.

During this time I’ve observed many changes in the healthcare sector in general, and in these hospitals in particular.

South Africa’s healthcare system compares favourably on a global level. Both the medical schools of the University of the Witwatersrand and the University of Cape Town are ranked in the top 100 in the world. Over the years, the region has produced many eminent healthcare workers. And the country is quite capable of delivering world-class healthcare to all its citizens.

But this is constantly being hampered by an increasingly unconducive environment.

Massive strain

The public sector hospitals in Gauteng, South Africa’s economic hub, are generally in bad condition. Chris Hani Baragwanath Academic Hospital is the third largest largest in the world, with almost 3200 beds and more than 6000 staff. Charlotte Maxeke Johannesburg Academic Hospital has 1088 beds and more than 4000 staff.

These large public sector hospitals provide tertiary and quaternary services to more than 250,000 inpatients and almost 1 million outpatients every year.

Most were built more than 50 years ago and have been poorly maintained. The crumbling infrastructure results in flooding, sewage leaks, lack of water, problems with the supply of medical air and oxygen, and electricity blackouts. Leaky plumbing creates a damp environment that favours pests such as cockroaches and rodents. Inadequate air conditioning results in working conditions that are unbearably hot or freezing cold. Both are harmful to patients.

Doctors and nurses are having to deal with a shortage of hospital beds on a daily basis.

Gauteng provides healthcare to many patients from other provinces, as well as surrounding countries, particularly Zimbabwe. The provinces of North West and Mpumalanaga do not have medical schools and therefore send patients for specialised tertiary and quaternary care, such as cardio-thoracic surgery and renal dialysis, to the Gauteng academic hospitals.

In addition, under-resourced regional and district hospitals result in primary and secondary patients receiving treatment in the tertiary or quaternary institutions because there is nowhere else for them to go.

Overcrowding and infrastructural issues negatively affect patient care. Hospital acquired infections with “super bugs” resistant to almost all known antibiotics are a major health challenge. Sewage leaks and inadequate plumbing increase the risk of infections.

Ongoing power cuts and water shortages compound the internal infrastructural issues at each hospital. There have been rolling electricity blackouts in the country as the government struggles to keep the power utility, Eskom, operational.

Each hospital has a diesel generator. But this emergency back-up does not always kick in during blackouts and load shedding. Patients in intensive care and the operating theatre are particularly at risk.

Water infrastructure, which has not been maintained by local authorities, is in a state of disrepair resulting in a growing number of water outages. In recent weeks, three of the largest hospitals in the province– the Helen Joseph Hospital, Rahima Moosa Mother and Child Hospital and Chris Hani Baragwanath Academic Hospital – all experienced a water outage that lasted several days.

Surgeons were scrubbing for theatre using buckets, people could not flush toilets, and patients were issued with bottled water and could not wash.

On top of all this, the Covid-19 pandemic is now raging in the province. This is proving to be the last straw for a buckling health system. Shortages of hospital beds, lack of oxygen supplies, inadequate ICU facilities are a few of the problems being faced.

Healthcare workers are exhausted and burned out.

How it got to this

There are multiple reasons for the current debacle. These include a lack of preventative maintenance, poor administration, corruption, poor forward planning, lack of financial resources, and a lack of strong governance at both municipal and provincial level.

The governance of the hospitals is complex and falls between different government departments. The Department of Infrastructure and Development, or Public Works has been tasked by the Department of Health to take care of the hospital infrastructure. This means that a hospital CEO isn’t directly responsible for maintenance of the building.

In turn this means that the system for responding to maintenance issues is not agile.

Bureaucratic processes designed to minimise corruption result in long delays. Management at all levels tends to put out fires rather than implement a long term strategy to improve the situation.

Facilities have also been affected by strikes about wage disputes. In some cases hospital facilities have been damaged during the industrial action.

Criminality is also a problem. Theft is common with wall mirrors, bathroom tiles, soft furnishings, even large potted plants disappearing. Most recently copper plumbing pipes were stolen from Charlotte Maxeke Johannesburg Academic Hospital while it stood empty.

The fallacy that South Africa has two healthcare systems

There is a perception of an “us and them” among many South Africans. People with medical aid feel relieved that they have access to private healthcare, which does not have all these problems.

This is a fallacy. The country has one healthcare system – the public academic institutions train the healthcare workers who work in both the private and public sector. If the public healthcare sector collapses, the private sector will follow.
The solution is proper management and accountability at all levels. South Africa spends enough money on healthcare (just over 10% of GDP), but there is terrible waste at many levels. The government is pursuing a National Health Insurance scheme, with the aim of pooling resources to provide “quality affordable personal health services for all South Africans, based on health needs, not socio-economic status”.

If implemented and governed properly, the new scheme is most likely the best solution to all the many problems facing country’s healthcare system. And it will allow South Africa to reach its full potential of providing excellent healthcare to all.The Conversation

Professor Daynia Ballot, Head, School of Clinical Medicine, University of the Witwatersrand

This article is republished from The Conversation under a Creative Commons licence. Read the original article.


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Is this article a advert for NHI?
The collapse of state hospitals have nothing to do with lack of money. It has to do with a lapse of competence.

Typical results of cadre deployment on the one hand and zero consequences for zero performance.
Whether you work and achieve results or do next to nothing, you still get your salary or in this case even an increase.

“Lack” of competence. fixed.

Great report Dr Ballot . I was in the management of a leading producer for hospital sanitary ware since the mid 80,s till mid 2000. I was involved in at least 80% of all hospital projects in SA. Simply zero maintenance since mid 90’’s. One could see the fast decline of PTA Academic , the .Kroonstad hospital , PE Hospital , Bethlehem …name them ,
And then the ANC constructed obscene expensive Hospitals in De Aar , Ladybrand to name a few .The architect explained that they were “monuments “ for the ANC !

Upington stood non-operational for a long time due to lack of training .

And now they want the private sector to fund NHI ? There is no way that this country can afford this and the end result will be disinvestment,

We require a team of people to do an audit of all hospitals , clinics and mortuaries to budget for repairs and training to maintain.

The dear professor experienced the sad but logical process of “transformation”.

Whenever people of a communalist background vote for transformation and redress, they always get it, but not in the way they anticipated.

Any democratic system enables ordinary people, with their cognitive ability and world views, to transform their infrastructure, services, and the aesthetics of their immediate environment, to reflect their mindset. This is true for Switzerland as well as for Zimbabwe.

No voter anywhere in the world can use his vote to build anything that is more sophisticated than himself. Over the longer term, the artworks, museums, schools, libraries, infrastructure, architecture, sewerage plants, power utilities, hospitals, the health of the banking system, and services merely reflect the level of sophistication of the average voter. The ballot box turns the mindset of that voter into services and infrastructure. In this article, the honourable professor describes that mindset, as he depicts the environment he works in.

We cannot have better results while we have the same voters. No amount of money can stop this unrelentless political-economic force that equalizes the infrastructure with the mindsets of the voters. Incompetence, negligence, naivety, stupidity, and criminality are instruments in the hands of the voter. The voter himself delivered these instruments of decay. The voter can’t blame the government or the officials because the voter appointed them.

Things won’t change for the better until the voter mans up and accepts responsibility for the outcomes of his indiscretions at the ballot box. That requires a level of self-examination and introspection that is far above the level of sophistication of that voter. That implies that the South African constitution actually guarantees the implosion of service delivery. Privatization will insert a circuit-breaker between the mindset of the voter and the quality of the services he depends on. Privatization will save countless lives, but the current agenda is still about “transformation” and “social justice”.

Well said Sensei — Wish I had your patience with words — My comments were clearly too harsh for this website !!

Casper, we are forced to beat about the bush, and to call a spade a manually-operated digging device, if we want our comments to slip past the sensors.


You are HALF right ie correct in the ANALYSIS of the cause.

And HALF wrong ie fundamentally wrong in the SOLUTION!

EVERYTHING you say about the degree of decadence being a DIRECT reflection of the stupidity and lack of sophistication of the average voter is correct.

But “Privatizing will fix this problem” ???

Never in a thousand years!

Think about it … privatisation depends on the users PAYING for the services rendered.

The problem is that the majority of the people demanding the services you want to privatize do NOT have the capacity (never mind inclination!) to pay for them.

So one will inevitably wind up with a two-tier system. A privatized system that is supported by a minority that CAN afford to pay for them.

And … the vast destitute majority who can afford nothing. And will therefore get nothing.

And on top of this … is an exploding population growth that is only amplifying this divide.

How do you think this scenario is gonna work out in practice???

Splendidly? And we all live happily ever afterwards … ??

Or will it rapidly implode al la the French Revolution – where the desperate poor chopped the heads off of the indifferent nobility???

Anyone who advocates the virtues of “Privatisation” HAS to explain how this is fixing this very same problem in that rapidly decaying bastion (erstwhile!) of Capitalism and Privatisation – the USA.

Privatisation in the USA is only OK in the affluent suburbia. It’s non-working in the Ghetto’s (where the quality of life – in every parameter you care to name is in freefall).

In my opinion, you CANNOT fix this problem by applying superficial band-aid solutions.

You have to recognize that it’s no good advocating slapping a shiny new roof on the house to fix “the problem”, when the problem is that the walls are collapsing because the FOUNDATION is non-existent.

You should keep in mind that privatization distributes pieces of an ever-growing cake, whereas public services redistribute parts of a shrinking cake. The so-called “socialist” Nordic nations with their large welfare schemes and free services actually privatized state-owned enterprises and defend the private ownership of property.

China is the biggest economic success story in history because they defend property rights and private entrepreneurship. This was successful to grow an entire nation out of poverty in one generation. Unaffordable social projects handicap the Western powers while it allows the one-party Chinese state to gain the upper hand in the competitive world economy. Property rights imply that people only have a right to the stuff they are able to pay for. The alternative is hyperinflation of the currency, and this is exactly where our policies of free unaffordable municipal services are taking us.

Ag nee man, Sensei!

You are displaying all the hallmarks of a consummate Politician or Economist, or debater, when they are confronted with a question they cannot answer.

You DELIBERATELY avoid answering the DIRECT question, and instead substitute with a distracting (and misunderstanding!) waffle about China.

If you have a REAL point about the usefulness of “privatization” being able to turn a “bad national situation around”, then you HAVE to be able to show that YOUR point is actually working in the USA.

If your thesis had ANY traction, then it would have been be EASY for you leap on my comment about the USA, and use it against me as the perfect example to show how “Privatization” is working to your thesis’ advantage in that country.

The USA has ALL the very principles that YOU posit are the key enabling features of your privatization theories.

They have VERY well-developed property rights. And did you not also mention “private entrepreneurship” was uber-important?? Of course you did! The USA is the very EXEMPLAR of the power of entrepreneurship!

So … EVERYTHING that YOU consider essential for “privatization” to actually work, and to tremendous advantage, is there – in abundance – in the USA.

Why CANNOT your proposition sustain itself in the USA???

Answer THAT direct question FIRST – to satisfaction – Sensei. And then you get permission to waffle afterwards!

As for the cause of China’s success …

We have been over that story before! Extensively.

Property rights certainly are an important facet of a successful nation, but they do NOT satisfactorily explain China’s ASTOUNDING success story, which is instead, MUCH more convincingly explained by the SUPERIOR quality of the Chinese governance, AND the far-reaching beneficial consequences of the original one-child policy (which would not have happened without this decisive leadership).

By comparison, India, which is a directly comparable nation to China, is a complete – and ONGOING – national disaster! All the things you rave about as being essential for national success ARE present in India. In abundance! And have been for DECADES.

Talking from above. Below,on ground level, Survival is what count, not in the medical sense, but shelter and food. Watch the so called informal living conditions. Diving in other peoples waist bin to scraps, bare handed, but nose covered, for anything, worth nothing for me, but them. The sinking of the Titanic must have been a sound festival of metal and human scream sounds. Watching a beautiful country going down is a unstoppable process. If the method is complaining. Like then, a waist of time.

If you can’t be entrusted with the little things you cannot be entrusted with bigger things.

The government received some of the best hospitals in the world (in the 90s) and now people are relieved when they have private medical aid so they can avoid it.

It goes against Common Law principles that a person may not identify a need in the market (in this case private medical care) and may not set up a business to provide for that need. And likewise it goes against a person’s rights to decide from whom he wants to procure his services (in this case medical services).

FIRST the government must be successful at government medical services and only THEN people will happily cancel their medical aids and use government medical facilities. This will be the only legal and ethical way to implement a NHS.

Amongst the ever-increasing and amorphous facets of the political spectrum are the chapels of political science and political myopia. As we can see, the consequences of political failures can be far worse than any natural disaster. It appears that the best way to redirect the political will away from the continuous distraction of the political gravy is by the politically cultural practice of intimidation. Within the chapel of political motivation the facets of fear and/or greed are permanent residents in some form or other.

The collapse of once properly-working government facilities is ENTIRELY due to the general LACK of the simple management principle that executive decision-makers MUST be the FIRST to eat their own dogfood.

In the case of health services, for example, it should be a condition of service that ALL politicians are COMPELLED to use ONLY government clinics and hospitals. No private hospitals or doctors for you!

A waste of valuable executive time for a “Minister” or “Provincial Premier” to spend their whole day shuffling around in slow-moving queues in crowded, over-stressed, facilities doing what the peasants have to do?

Not at all. It is the salutary lesson a good leader will seek out. And an incompetent poser will seek to avoid.

When politicians get the opportunity to EXPERIENCE (and not merely inspect!) first-hand the quality of the services THEY promised, they get the opportunity FIX the problem first-hand. It is an invaluable learning experience!

And if these services are non-existent or incompetent, then THEY are the FIRST to suffer (and yes, die, if needs be!).

When elected politicians are forced to experience the reality they (or their forbears) created – and CANNOT run away from escaping – and fixing – the bad consequences – THEN ONLY will the public governance situation turn around.

As much as one may detest the species, it is “Politicians” that are THE change-agents of the society we create for ourselves.

Sadly, the author of this article doesn’t seem to understand this is the underlying problem – even though it stares in her face at every corner.

Anyone knows what happened at Kempton Park Hospital?

This is the steady decline due to ANC policy of BEE led transformation, corruption, patronage politics and mismanagement.

SA is dying under the ANC.

When everybody is responsible, nobody is.

Public Works needs to go. If the municipal health manager for Kimberly who is made responsible for Kimberley hospital wants to, it can contract with Public Works for repairs. If not, it contracts locally.

It is not as if Public Works has its own army of plumbers and electricians – they subcontract in any event!

Transfer the assets to Health (or the municipality?). There are town hospitals that seem to be quite successful running one facility that is half state and half private, municipal control could work.

This is one lot that really trample their own kind.

End of comments.



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