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SAMJ: South African Medical Journal

versión On-line ISSN 2078-5135
versión impresa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.104 no.11 Pretoria nov. 2014 



Bureaucracy and clinical performance



To the Editor: There currently seems to be a view among managers in the Department of Health that the best way to improve the clinical performance of staff, particularly in peripheral clinics, is to increase the bureaucratic demands upon them.

Consider, for instance, the plight of the midwife working in a small clinic in KwaZulu-Natal. Hers is a very demanding task. For each new patient (I hate the word client) she must take the history, do the lab tests (haemoglobin, HIV, rhesus, a syphilis test, urine dipstick), take blood specimens for CD4+ and creatinine if the patient is HIV-positive and for rhesus antibodies if she is Rh-negative, check blood pressure and weight, do a complete medical examination, including a Pap smear if the patient is booking early enough, provide the necessary health and post-test counselling, dispense the necessary medications, and in addition fill in no less than nine documents if the patient has HIV. They are: (i) the huge antenatal register; (ii) the daily clinic attendance register; (iii) the isoniazid prevention therapy register; (iv) the antenatal record; (v) the HAST (HIV/AIDS, sexually transmitted infection, tuberculosis) record; (vi) the TB screening checklist; (vii) the antenatal checklist; (viii) the health education checklist; and (ix) the MomConnect register. These are regarded as necessary so that managers can have easy access to statistics, and they seem to be the main, often only, measure of clinical compliance and competence.

It is no mystery that midwives, even when assisted by enrolled nurses to fulfil some of these roles, struggle to keep in focus the obstetric problem the patient has presented with, battle to concentrate on relationship building, and find it hard to create time to structure a really logical and effective management plan. Too often the paperwork is intact but the clinical responses are defective, and the exercise has ended up defeating itself by its complexity.

This problem is not confined to the clinics. In many hospital wards, registered nurses spend more time meeting the bureaucratic demands of their employers than they do directly caring for their patients, and forests are decimated to produce the paper involved!

A careful rethink by senior management is required, because all this bureaucracy probably increases rather than decreases the rate of litigation, quite apart from not improving the standard of care.


J V Larsen

Howick, KwaZulu-Natal, South Africa.

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