Managers’ decision making power on infrastructure development, supplies and

Managers’ decision making and implementation power on infrastructure development

and maintenance97 _{and essential drugs, medical supplies and equipment}98 _was

determined by national and health policies, GHS directives and the availability of funds.

Pressures from superiors at the GHS, frontline workers, donors and clients influenced managers’ decision on prioritising infrastructure development in the face of resource constraints. For example, Adom hospital managers were compelled to quickly repair the O&G theatre doors after the department staff sent a memo to the hospital management threatening not to work if the O&G theatre door was not repaired within two weeks. The threat was precipitated when the already weak theatre door fell on a nurse, which made it unsafe to perform surgeries in the theatre. In another instance in

96 _{Interview with a hospital manager, 05/03/2014.}

97 _{Hospital managers had to make decisions on infrastructure development for their hospitals, because the} Ministry of Health (MOH), which is the government body responsible for providing infrastructure could not meet the infrastructure needs of the individual public hospitals.

Grace hospital, management was compelled by the regional health directorate and a donor to urgently develop a comprehensive O&G facility. Interviews with hospital managers, the O&G specialist and a review of correspondences to the hospital from the regional health directorate, suggested that the directorate felt that the specialist was being underutilised, because of the lack of a comprehensive O&G facility for the specialist to optimise the use of his skills. So the regional health directorate had given the hospital an ultimatum to construct an O&G facility within a period of one year, to enable the specialist to practice his skills or risk losing him to a transfer. Additionally the hospital risked losing a donation of theatre equipment from an international donor, for the setting up of a comprehensive O&G facility. The donor threatened to donate the equipment to a different facility by a given deadline if the theatre was not set up. A hospital manager explained how such pressures influenced their decision to stop spending money on other personal and work needs of frontline workers and channel all their IGF to the construction of a theatre: ‘...we said no, we cannot let the equipment go,

because if they take them out of the compound, I do not know when we will ever get money to buy theatre equipment. So we suspended everything.’99

Additionally hospital and department managers as well as frontline workers faced pressure from the teeming number of clients who visited the hospitals. The hospitals tried to cope with the overwhelming number of clients by referring clients to other facilities. Also Adom hospital introduced a consent form to discourage clients. While these measures discouraged some clients, others were not deterred and insisted on being attended to in the facilities.

In the face of resource constraints, in satisfying one need hospital managers denied other personal and work needs of frontline workers. For example, during the period of study both hospitals complained that they could not offer ultra-scan services, yet scanning during pregnancy is a prerequisite for clinical decision making. Both hospitals explained that they had one ultra-scan machine, which had broken down, but they did not have money to buy new ones. Yet Adom hospital spent a huge chunk of their IGF on snacks for staff. Pregnant clients in both hospitals were referred to private facilities and that required them to travel out of the hospital, which put them at risk. Frontline workers found this inappropriate and embarrassing and felt their managers were not responding to their work needs.

A national health directive for hospitals to first buy drugs and medical supplies from the national medical stores and only buy from the open market when there is none in the medical stores, affected the timing and quality of drugs acquired for service delivery. Hospital managers in Grace hospital confirmed that sometimes some of the essential supplies and drugs acquired from the national medical stores were of inferior quality and other times expired drugs that were acquired from the medical stores had

to be returned.100 _{Such occurrences disrupted service provision, which frustrated both}

managers and frontline workers.

As part of coping strategies, managers used available opportunities to influence decisions on infrastructure projects and to acquire essential supplies that would otherwise require bureaucratic procedures to accomplish. In two separate interviews hospital managers from the two hospitals reported that they took advantage of an impending regional peer review exercise to sidestep bureaucratic procedures to acquire basic supplies that their hospitals lacked and to carry out maintenance and repair works on existing infrastructure.

Managers depended on external suppliers for some of their essential supplies and equipment. Sometimes suppliers supplied hospitals with inferior products after having presented superior samples and received approval. In an interview with two hospital managers in Grace hospital one of them shared hospital managers and workers’ experiences with suppliers who presented inferior products: ‘Sometimes after

winning the bid the suppliers will supply inferior items sealed. So it is only when they

[frontline workers] open to use it that they realise that it is an inferior product.’101 _Managers

coped with unreliable suppliers by involving frontline health workers who are the end users of requested products in the procurement process, by showing samples to them for approval before purchasing. While some frontline workers appreciated managers’ initiative to involve them in decision making on drugs, medical supplies and equipment, others complained that sometimes the medical supplies and equipment that were supplied to them were inferior to the samples that they were initially provided. Such frontline workers perceived that managers conspired to cheat the

hospital by acquiring inferior products, so they did not trust their managers.102 _The

mixed responses from frontline workers gave managers mixed feelings. Sometimes managers felt that workers appreciated the initiative to involve them, but sometimes

100 _{Grace hospital, interview with two hospital managers, 06/08/2013.} 101 _{Grace hospital, interview with two hospital managers, 06/08/2013.}

managers felt frustrated, when some workers expressed doubts, which suggested that managers were not honest.