Sbrana Psychiatric Hospital

So this week was an interesting one at work. On Monday when Vernon and I got to work Moseweu, one of the health inspectorate officers was late, "Great, you're here! Let's go!" Apparently it was planned that we'd be going on the official accreditation baseline assessment visit to the Sbrana Psychiatric Hospital, which took place all this week. No one bothered to tell us that, but it was a great surprise; we love any chance to take a break from office work and see how what we're working on translates in the actual hospitals and affects real people.

Sbrana is the only psychiatric hospital in the country. It's located in the town of Lobatse, which is about an hour southwest of Gaborone. This week was different than the previous inspections I went on. Instead of the HI officers conducting they're own inspection, we were accompanying a team of 4 doctors/nurses/public health specialists from an organization called COHSASA (Council on Health Service Accreditation in Southern Africa). Its an organization that measures health facilities against a set of standards and accredits them, just like any accreditation process with schools, etc. The Ministry of Health has been using COHSASA as an outside accreditor for some of its hospitals/clinics because its a good way of improving and ensuring certain standards of care. I learned a ton this week about the importance of policy and standards in terms of health, but a lot of what I saw this week also made me very upset and angry.

Sbrana is a brand new facility that hasn't even had the official ribbon cutting yet. From the street it looks beautiful, and you can see from the photos that it's far from the stereotypical third-world hospital stereotype. However, there are major problems within it, starting with the fact that this facility has some horrible flaws with its design and the Chinese firm contracted to build/furnish it obviously did no consulting with anyone who works in psychiatry, or in a hospital for that matter. Major design flaws include but are not limited to:

• These bizzare patient verandas so they can get sunlight. They have glass on top and open bars on the bottom.
• Open flower beds within the hospital. You'll just be walking and then there's a big square open dirt pit, some empty and some filled with a few plants. Not only is this a safety hazzard when it's located in a forensic ward (which holds criminals pleading insane) because they can bury weapons there, but also its dangerous because some of the plants are poisonous and the hospital has some intellectually disabled patients who will eat them (I'm thinking now of Erin eating all of my mom's merigolds).
• Fire exits/escapes that lead to nowhere or to chained doors which only the hospital manager has a key to
• To many reception areas, about half of them are unnecessary and therefore empty
• Glass walls/doors everywhere. In a psychiatric hospital, many of these are smashed
• Burgler bars/curtain rods in the rooms - a perfect place for psychotic patients to hang themselves.

They also have a lot of expensive equipment that either they don't really need or doesn't work, yet are missing vital items such as working suction machines, a defribrulator, and even rubber gloves, and beds (yes beds). There are only beds in 2 of the wards. They're still "waiting for the rest to be assembled" so the patients have been sleeping on matresses on the floor for 8 month. Did I mention the temperature control doesn't work? This is bad when patients are in little track suits/bathrobes and Lobatse is one of the coldest cities in Botswana (it gets down to around 30 at night). The wards are also way overcrowded. For example, Male Acute Ward 2 is supposed to have a bed capacity of 36, but currently has 70 patients. Yet, the hospital has a playground and no kids to play on it, and a lot of other things it doesn't need.

This makes me very mad, because the government just spend millions of dollars on this new facility which, according to the South Africans we were with, can't be accredited as it is now. A lot of money was wasted: money that the government doesn't have and which might have come from foreign aid. The South African accreditors were also talking to me a lot about the importance of policy development and how crucial it is to improving the quality of care in hospitals, especially in developing countries. Most of the hospitals haven't developed guidelines that answer questions like, "How do we get a patient's consent?" and things like that. That can lead to problems I saw this week, such as a patient being sent to seclusion for almost a month and non-authorized staff delivering drugs. Documentation, or lack thereof, is also a really big problem, and the accreditors are real sticklers about it, because a lot of these hospitals don't keep very good records so its hard to tell who is an isn't following the rules. Unlike in the US, hospitals haven't been monitored for things like this up until now and patients don't have the resources to sue if they're not being treated right. Take aways for the week as an IR major: when development projects are done irresponsibly by contractors who feel like they can get take advantage of poor countries and get away with it, real people suffer. Also, policy can be a very effective tool to make progress in the quality of care because if you create standards and then work with facilities to identify where they're failing and monitor them to help them reach those goals it will help foster a collective movement to improving a sustainable healthcare infrastructure.