RUNNING THE SHOW: Ministry of Health Permanent Secretary, Kolaatamo Malefho
The Council for Health Service Accreditation of Southern Africa (COHSASA), the only internationally accredited quality improvement and accreditation body for healthcare facilities based in Africa, has been for past four years trying to accredit Botswana hospitals, but with zero success.
Ministry of Health pays COHSASA P1 million for every visit they undertake to the country and this has been ongoing for 48 months. At one stage, Healthshare, a South African consulting company was engaged to do a baseline on accreditation, but it is not clear what became of its report which was handed to the permanent secretary, Kolaatamo Malefho.
The past 19 or so years have seen over 600 facilities throughout the continent enter the COHSASA programme to improve the quality and safety of the healthcare services they provide to patients, but the vast experience of this organisation has been short played by Botswana’s Ministry of Health. Several recommendations made towards the improvement of the health facilities in the country have been shoved under the carpet, and many believe poor decision making on spending is letting hospitals down.
“Through its integrated and system strengthening process, COHSASA assists a range of healthcare facilities in Southern Africa to meet and maintain quality standards. This range includes hospitals, clinics, general and family practitioners, rehabilitation centres, hospices and laundries with standards being developed for many other services. There is a strong focus on building capacity to help healthcare professionals measure themselves against the standards,” an extract from COHSASA website explains.
Strictly applied quality improvement methods can improve patient safety and the quality of care by identifying deficiencies, guiding interventions and monitoring progress. COHSASA's web-based information system identifies deficiencies and weaknesses in healthcare facilities and creates prioritised quality improvement plans to overcome them. The data generated helps authorities to provide cost-effective interventions. The Ministry of Health officials were asked questions below and did not respond to our questionnaire which was with them for seven days:
For how long has COSASSA been engaged in the accreditation process of local hospitals?
How much has the Ministry spent so far on COSASSA since the commencement of this task?
When do you expect them to finish the accreditation process?
What are the initial recommendations from COSASSA and what has been your response?
Is it true that Healthshare was once engaged to do the same job and their recommendations were ignored and COSASSA was engaged instead?
How many hospitals are on the verge of accreditation so far?
Do the impediments to accreditation have much to do with hospital administration or are they much dependent on actions and decisions by the Ministry of Health eg hospital staffing, shortage of equipment…etc
Healthshare report was sent to hospitals and it became clear to hospital managements around the country that the recommendations were far beyond their mandates. They opined that the Ministry of Health headquarters was based placed to act on the recommendations since their bordered more on budgetary issues. Instead on acting on those recommendations, the Ministry officials chose to engage another organisation, COHSASA to do a baseline on accreditation.
With hospitals there were a number of recommendations which could have helped improve the status, among some of the issues raised were poor maintanance, shortage of health and support staff, overcrowding, lack of resources and equipment, among others challenges.
The report also noted that health in Botswana is too centralised, with all decisions coming from Ministry headquarters. The top down approach has led to situations where hospital management can’t even make basic decisions on recruitment without a word from the permanent secretary. C band and cadres above are all hired from the Ministry headquarters. Hospital management can only hire those on A and B bands, and these posts are frozen to date.
PRINCESS MARINA DOWNGRADED The Princess Marina Referral hospital was at one stage graded to 78 percent by COHSASA but only to be downgraded the following because of its deteriorating status. The hospital has a bed capacity of 565 but on average it admits 750 patients, which far exceeds its capacity without any additional resources or staffing provided.
The issue has been raised with the Ministry of Health but to no avail, health workers at the hospital have in the past indicated that the resources are stretched at Marina. The overcrowding affects staff-patient ratio while dragging down the patient care as well.
WeekendPost has established that Princess Marina has no isolation ward, where it can keep infectious patients; instead the isolation ward was handed over to the Spinalis section at the instruction of permanent secretary Kolaatamo Malefho. This publication has also established that infectious cases are taken to private wards. “If patients at Marina were litigious people, they would sue almost every day,” said a Medical Officer at the hospital.
Princess Marina Hospital responds
What is the bed capacity of Princess Marina Hospital? Bed capacity is 567
On average how many patients do you admit at the hospital? Average 750
How often do you have a mismatch between bed capacity and admission figures? During the year Princess Marina Hospital experience about 750 bed occupancy against the 567 official bed capacity. Usually during the festive season most people go to their home villages and the hospital experiences lower patient volumes with an average occupancy of about 450, so it’s usually less hectic during festive season but the services go on as usual.
Does the much talked about overcrowding have impact on patient/nurse ratio? Yes the ratio increase leading to increased workload for nurses.
What measures do you put in place when the hospital is stretched in terms of resources? The hospital has relocated some of its services to the nearby facilities as follows;
Princess Marina Hospital has relocated some of its services to the nearby facilities. For example Eye Clinic and Open Heart Surgery services as well as stable neonates (premature babies) has been relocated to Scottish Livingstone Hospital. Princess Marina Hospital has also relocated the diabetic clinic to block 6 clinic.
We have also introduced block booking whereby patients see doctors on appointment- for Out Patient Department Clinics e.g. gynaecologist, ENT(Ear Nose and Throat) Clinc, surgical and oncology among others.
In addition to that, PMH has also outsourced a 24hrs laundry service so that healthcare workers can concentrate on their core duties.
Rumatology Services (Joints) patients are seen at Extension 2 Clinics on Fridays and on Tuesday mornings and Thursday afternoons at PMH.
Dermatology (Skin condition patients) Services has been relocated to Broadhurst 3 Clinic. Patients are attended at Princess Marina Hospital on Tuesdays, Wednesday and Fridays only. So basically by relocating these we are trying to decongest the hospital.
What is the capacity of Marina’s Intensive Care Unit (ICU)? Is it adequate for the load Marina is currently experiencing? PMH has an 8 bedded Intensive Care Unit and definitely it is not adequate looking at our patient volumes. Some of our patients are transferred to Scottish Livingstone Hospital in Molepolole. We also outsource ICU services at Bokamoso and Gaborone Private Hospitals.
Does Princess Marina Hospital has an Isolation ward? If no, where do you house infectious patients? We don’t have an isolation ward however we have isolation rooms for infectious disease patients.
Is it true that the Isolation ward was handed to Spinalis section in 2012? Yes it is true that it was handed over to Spinalis to cater for the rising road traffic accident injuries. We will continue to priorities our facilities where necessary.
Are you involved in the budgeting process for the hospital? Is it need and output based? PMH is involved in budgeting, and yes it is need and out based but with the country not out of the recession yet, we cannot get all that we need. Ministry of Health is however very supportive.
Does the hospital management do any recruitment of health workers such as nurses and medical officers or all is done by the Ministry of Health? No, we don’t do recruitment however we present our human resource needs and submit to Ministry of Health who in turn does the recruitment.
Are you happy with the morale of the health workers in your hospital? Yes we are happy with our staff morale however we feel we need to do more in terms of staff welfare issues. We are currently planning award ceremonies to reward high performance culture, we also have staff welfare committee which looks into the welfare of our employees, and we have staff sports games to improve fitness of our employees and bonding. We really thank our staff for working very hard under the current working conditions.
In June 2019, a case involving the Attorney General was brought before the High Court, in which the applicant Letsweletse Motshidiemang challenged Sections 164 (a) and 167 of the Penal Code. The applicant contended that these sections are unconstitutional because they violate the fundamental rights of liberty and privacy.
The applicant argued that these sections violated his right and freedom to liberty as he was subject to abject ignominy. These laws subjected the LGBTIQ community to brutal and debasing treatment through social control and public morality. On the 1st of November 2017, the Botswana High Court further allowed Lesbians, Gays and Bisexuals of Botswana (LEGABIBO) to join the case as amicus curiae.
However, in July 2019, the respondents, in this case, i.e. the Government, filed an appeal against this iconic High Court ruling seeking re-criminalization of homosexuality. Human Rights Group has criticized this move of the Government all over the world. The appeal was heard before five judges at the Court of Appeal on Tuesday. The State was represented by Advocate Sidney Pilane, while LEGABIBO and Letsweletse Motshidiemang were represented by Tshiamo Rantao and Gosego Rockfall Lekgowe, respectively.
Non-Governmental Organizations advocating for the LGBTIQ+ community joined the two parties at the Court of Appeal during this case. They argue that the minority group should enjoy their rights, especially the right to privacy and health. Botswana Network on Ethics, Law and HIV/AIDS (BONELA) Chief Executive Officer, Cindy Kelemi says the issues being raised by LEGABIBO are that as individuals belonging to the LGBTIQ community, they have and must share equal rights, including the right to privacy, which also speaks to being able to involve in sexual activities, including anal sex.
“Those rights are framed within the constitution, and therefore a violation of any of those rights allow them to approach the courts and seek for redress. We do not need the law to be regulating what we do in the privacy of our homes. The law cannot determine how and when we can have sex and with who, so the law does not have any business in that context. What we are saying is that the law is violating the right to privacy,” she said on the sidelines of the decriminalization case in Gaborone on Tuesday.
The first case involving the homosexual act was the Utjiwa Kanane vs the State in 2003. Contrary to section 164(c) of the Penal Code, Kanane was charged with committing an unnatural offence and engaging in indecent practices between males, contrary to section 167. The conduct at issue involved Graham Norrie, a British tourist, and occurred in December 1994. (Norrie pleaded guilty, paid a fine, and left the country.)
Kanane pleaded not guilty, alleging that sections 164(c) and 167 both violated the constitution. The High Court ruled that these sections of the Penal Code did not violate the constitution. Kanane then appealed to the Court of Appeal. BONELA CEO recalls that in its judgment then, the High Court indicated, Batswana were not ready for homosexual acts. Twenty years later, the same courts are saying that Batswana are ready, she says.
“They gave the explicit example that shows that indeed Batswana are ready. There are policies and documents in place that accommodate people from marginalized communities and minority populations. The question now is that why is it hard now to recognize the full rights of an individual who is of the LGBTI community?” She further says intimacy is only an expression. The law that restricts homosexuality makes it hard for LGBTIQ members to express themselves in a way that affirms who they are.
“We want a situation where the law facilitates for the LGBTIQ community to be free and express themselves. The stigma that they face in communities is way too punitive. They are called names; some have been physically violated and raped at times. It shows that the law doesn’t not only prevent them from expressing themselves, it also exposes them to violence.” The law on its own, Kelemi submits, cannot change the status quo, adding that there is a need for more awareness and education on human rights and what it means for an individual to have rights.
“As it is now, it is very tough for some to do that because of a legal environment that is not enabling. We also want to see a situation where LGBTIQ+ people can access services and be confident that they are provided with non-discriminatory services. It is challenging now because health care providers, social workers and law enforcement officers believe that it is illegal to be homosexual. What we are saying is that if you have an enabling law, then that will facilitate for people to be able to express themselves, including accessing health services,” Kelemi said.
“As we are doing this advocacy work, one of the issues that we picked up is that there is lack of capacity, especially on the part of healthcare workers. We noted that when we provide services or mobilize Men who have sex with other men (MSM) to access health facilities, health care workers are not welcoming, forcing them to hideaway. We must put an end to this to allow these people the freedom that they equally deserve.”
The President, Dr Mokgweetsi Masisi, has declared as an act of corruption the attitude and practice by government officials and contractors to deliver projects outside time and budget, adding that such a practice should end as it eats away from the public coffers.
For a very long time, management problems and vast cost overruns have been the order of the day in Botswana, resulting in public frustrations. Speaking at the commissioning of the Masama/Mmamashia 100 Kilometres project this week, Masisi said: “There is a tendency in government to leave projects to drag outside their allocated completion time and budget. I want to stress that this will not be tolerated. It is an act of corruption, and I will be engaging offices on this issue,” Masisi said.
In an interview with this publication over the issue, the Director-General of the Directorate on Corruption and Economic Crime (DCEC), Tymon Katholo, says, “any project that goes beyond its scope and budget raises red flags.” He continued that: “Corruption on these issues can be administrative and criminal. It may be because government officials have been negligent or been paid to be negligent by ignoring certain obligations or procedures. “This, as you may be aware has serious implications on not only of the economy but even the citizens who use these facilities or projects,” Katlholo said, adding that his agency is equally concerned.
According to the DCEC director, the selection, planning and delivery of infrastructure or projects is critical. In most cases, this is where the corruption would have occurred, leading to a troubled project. A public finance expert at the University of Botswana (UB), Emmanuel Botlhale, attributes poor project implementation to declining public accountability, lack of commitment to reforming the public sector, a decline in the commitment by state authorities and lack of a culture of professional project management.
In his research paper titled, ‘Enhancing public project implementation in Botswana during the NDP 11 period,’ Botlhale stated that successful implementation is critical in development planning. If there is poor project implementation, economic development will be stalled. Corruption is particularly relevant for large and uncommon projects where the public sector acts as a client, and experts say Megaprojects are very likely to be affected by corruption. Corruption worsens both cost and time performance and the benefits expected from such projects.
Speaking during this week’s Masama/Mmamashia pipeline commissioning, Khato Civils chairman said Africans deserve a chance because they are capable, further adding that the Africans do not have to think that only Whites and Chinese people can do mega projects. During his rule, former president Ian Khama went public to attack Chinese contractors for costing the government a move that ended up fuelling tensions between China and Botswana after Khama dispatched the then Minister of Foreign Affairs, Pelonomi Venson Moitoi, to China to register Botswana’s complaints with Chinese government-owned construction companies. Botswana had approached the Chinese government for help in its marathon battle with Chinese companies contracted to build, among others, the failed controversial Morupule B power plant and refurbishment of Sir Seretse Khama International Airport (SSIK).
A legal battle between former Botswana Democratic Party (BDP) legislator Samson Moyo Guma and First National Bank (FNB) over a multimillion oil refinery project intensified this week with Justice Zein Kebonang referring the matter to Court of Appeal for determination. The project belongs to Moyo Guma’s company called United Refineries which he has since placed under judicial management.
The war of words between Moyo Guma and FNB escalated after the company’s property worth millions of Pula were put up for sale in execution by the bank and scheduled to take place on 8th October. It emerges from Court papers that the bank had secured an order from the High Court to place the company’s property under the hammer.
Moyo Guma then also approached the High Court seeking among others that the public auction scheduled for 8th October 2021 be stayed. He contended that the assets that were to be sold belonged in reality to United Refineries and that as the company had been under judicial management at the time of the attachment, the intended sale in execution was unlawful.
He also sought the Court to declare that the writs of execution against the properties of guarantors and sureties of United Refineries Botswana Holdings Propriety Limited (the company) are unlawful. Moyo Guma also sought a stay of the execution against the property known as Plot 43556 in Francistown, that is, the land buildings, plant and machinery which make up the property and any all immovable or movable property belonging to the guarantors and sureties of the company pending finalization of the winding up of United Refineries.
But FNB disputed Moyo Guma’s assertions and submitted that the properties in question belonged to TEC (Pty) Ltd and not United Refiners. TEC Pty Ltd which is one of the shareholders in United Refineries is one of the sureties and co-principal debtors of a debt amounting to P24 million owed by United Refineries to FNB. FNB argued in papers that the properties belonged to TEC because it was TEC which had passed a covering mortgage bond in its favour over the property it now sought to execute.
Moyo Guma submitted that the covering mortgage bond passed in favour of FNB did not tell the full story as the property in question was in truth and fact owned by United Refineries and not TEC Pty Ltd. He maintained that the shares had been had been passed by the company in exchange for the properties in question and that the parties had always been guided by the spirt of the share agreement in dealing with each other despite delays in the change or transfer of ownership of plots 43556 and plot 43557 in Francistown.
Kebonang said it was clear to him that the two plots (43556 and 435570 belonged to United Refineries notwithstanding that TEC (Pty) Ltd had passed a mortgage bond over them in favour of FNB. “For this reason the properties were immune from attachment or sale in execution so long as the judicial management order was in place,” he said.
The background of the case is that Moyo Guma together with five other investors, namely Elffel Flats (Pty) Ltd; Mmoloki Tibe; TEC (Pty) Ltd; Profidensico (Pty) Ltd and Tiedze Bob Chapi, each bound themselves as sureties and co-principal debtors in respect of a debt owed by a company called United Refineries Botswana Holdings (Proprietary) Limited (the Company), to First National Bank Botswana (FNBB) (1st Respondent).
FNB had extended banking facilities to the company in the amount of P24 million which was then secured through the suretyship of Moyo Guma and other shareholders. Court records show that Moyo had on the 11th February obtained a temporary order for the appointment of a provisional judicial manager in respect of United Refineries and it was confirmed by the High Court on 24th September 2019.
In terms of the final court order by the High Court issued by Justice Tshepho Motswagole all judicial proceedings against the company, execution of all writs, summons and process were stayed and could only proceed with leave of Court. Court documents also show that First National Bank had sued the company and the sureties for the recovery of the debt owed to it and through a consent order, the bank withdrew its lawsuit against the company.
But FNB later instituted fresh proceedings against Moyo Guma and did not cite the company in its proceedings. “There is no explanation in the record as to why the Applicant was now reflected as the 1st Defendant and why the company had suddenly been removed as the 1st Defendant. There was no application either for amendment or substitution by the bank,” said Justice Kebonang.
FNB had also argued that it sought to proceed to execute against Moyo Guma and other sureties on the basis of the suretyship they signed and that by signing the suretyship agreement, Moyo and other sureties had renounced all defence available to them and could therefore be sued without first proceedings against the principal debtor (United Refineries). The question, Kebonang said, was that can FNB proceed to execute against Moyo Guma and other sureties on the basis of the suretyship contracts they signed?
“The starting point is that the Applicant (Moyo Guma) and others by binding themselves as sureties became liable for debts of the principal debtor and such liability is joint and several. He said the consequences of placing the company under judicial management means that every benefit extended to it should also extend to sureties.
“If the company is afforded more time to pay or its debt is discharged, reduced or compromised or suspended the obligation of sureties is to be likewise treated. It follows in my view that where judicial proceedings are suspended or stayed against the company, then any recourse against the sureties is similarly stayed or suspended,’ said Kebonang.
He added that “In the circumstances of this case, it seems to me that so long as the company is under judicial management, the moratorium that applies to it must also apply to its sureties/guarantors and no execution of the writs should be permitted against them. Any execution would be invalid.”
“Mindful that there is judicial precedent on this point in Botswana, at least none that I am aware of, and given its significance, I consider it prudent that the Court of Appeal must provide a determinative answer to the question whether a creditor can proceed against sureties where a company is under judicial management,” said Kebonang.
Pending the determination of the Court of Appeal, he issued the following order; the execution of writs issued in favour of FNB against Moyo and other sureties/guarantors of United Refinery are hereby stayed pending the determination of the legal question referred to the Court of Appeal.