Part 1 of 2.
Everyday care in a South African hospital
A sick child arrives in casualty. A clerk records the admission. The doctor writes in the paper folder. Blood tests and x-rays are ordered. Results appear later on a laboratory portal, imaging in another system. The ward team keeps its own task lists and handover notes. Registrars and interns work in paper records, shared documents, WhatsApp messages and other tools, carrying key decisions from one step to the next.
Versions of this scenario unfold daily in South African public hospitals, large and small, where a mix of institutional, departmental and private digital tools coexist with paper records.
Image: Newsday – https://newsday.co.za/south-africa/11319/south-africa-has-the-biggest-hospital-in-the-southern-hemisphere/
Chris Hani Baragwanath Academic Hospital, or Bara, is the biggest public hospital in Africa. It has 2,680 inpatient beds, serves close to 1.9 million people and is a major referral, training and research site. Most clinical departments at Bara still rely on paper records. At the same time, laboratory, radiology and admissions run on separate legacy electronic systems. Staff use applications such as Google Forms, WardWorx and Trello on their personal devices.
A March 2026 paper in the Wits Journal of Clinical Medicine describes this setting, noting the lack of integration at Bara between the various systems, with concerns including data fragmentation and patient confidentiality.
How work gets done
An important reason why hospitals like Bara are able to function is because their staff develop workarounds – “duct taping” – across information gaps.
Image: OpenAI
Different hospital and provincial systems handle admissions, laboratory results and radiology. But local teams keep their own lists, handover notes, schedules and task trackers. The clinicians put these pieces together at the bedside, on ward rounds and during handovers. They know where information is, which list is current, and how to keep the care moving.
In Bara’s paediatric surgery department, daily work involved WardWorx for tasks, HealthSpace and Google docs for operations and notes, Google Calendar and typed theatre lists for scheduling, Google docs for morbidity and mortality and central line notes, Google doc call sheets and a weekly document for patient lists, and the NHLS website for test results.
A 2025 study describes the same pattern, showing how staff in public hospitals improvise with tools like WhatsApp because institutional systems do not properly support the work.
What emerges from these descriptions is hospitals that do not lack for digital tools but are without a single digital “home” for work.
South Africa’s digital health strategy
South Africa’s digital health strategy lays a path toward common platforms, interoperable data and a comprehensive longitudinal electronic health record. Progress, however, has been slow. A 2025 Gauteng study describes poor interoperability, conflicting standards and duplication. A 2023 review points to other familiar obstacles: infrastructure, governance, training and implementation processes.
Improvisation has its limits
A system that depends on the duct tape of local knowledge, individual memory and collective improvisation is hard to govern and hard to improve.
Duplicate data entry, confusion between software versions, confidentiality risks and siloed data create extra work, increases the risk of error and makes for avoidable effort at almost every step.
The Bara paper explains why Epic and other commercial EHR platforms which promise to resolve some of these challenges have been judged unrealistic for this setting: cost, infrastructure requirements, connectivity, staffing needs and limited flexibility.
The risk of making things worse
The answer to digital disorderliness is not to ban local tools and improvisations. Nor is it to impose a monolithic replacement; a rigid EHR system can easily add clicks, slow access to information and break routines that are relied on to keep care moving.
Banning informal tools before a better alternative is in place will not solve the underlying coordination problem. Digital reform has to bring order without making daily work harder.
The goal is to learn from the improvisation while reducing the need for it.
Reasons for optimism
There are signs of progress. The Western Cape has built a more mature digital ecosystem, including an electronic Continuity of Care Record (eCCR) and linked services. Published work suggests real gains, even if the job is still unfinished.
National systems such as the Health Patient Registration System (HPRS) are an important foundation.
There are also reasons for optimism at hospitals like Bara. The raw material for improvement exists. Staff know what information is vital, where the pain points are and which unofficial tools meet real needs. That is valuable knowledge. The workarounds offer clues about what a better system must do.
Digital development is therefore possible. The challenge is to make it coherent, affordable and workable in a range of different settings.
The way forward
At Bara, the paediatric surgery service was chosen for the first phase of a system improvement project. The department was small enough for close collaboration, big enough to show impact, already had experience with electronic health records, and had staff buy-in because duplicate data entry had become such a burden.
The Bara paper is important because it starts with day-to-day workflow problems in a real clinical service. It takes existing practices seriously and points to the next step: bringing order, standards and continuity to the digital environment.
My second article will look at what the team at Bara built and what can be learnt from their experience.
References
- Scribante J, Gibson E, Dangor Z, Cambitsis A, Phillips R, Makgamathe K, et al. Digital health records in South Africa: a template on how this can be achieved in the public sector. Wits J Clin Med. 2026;8(1):43-48.
- National Department of Health, Republic of South Africa. National digital health strategy for South Africa 2019-2024. Pretoria: National Department of Health; 2019.
- Chuma KG. ‘A tough nut to crack’: inconsistent standards as roadblocks to data interoperability of health information systems in public hospitals in the Gauteng Province of South Africa. Oxford Open Digit Health. 2025;3:oqaf013.
- Zharima CZ, Griffiths F, Goudge J. Exploring the barriers and facilitators to implementing electronic health records in a middle-income country: a qualitative study from South Africa. Front Digit Health. 2023;5:1207602.
- Kapepo M, Van Belle JP, Weimann E. WhatsApp as an improvisation of health information systems in Southern African public hospitals: a socio-technical perspective. Procedia Comput Sci. 2025.
- Gumede S, Dyers R. The user experience of an electronic medical record: a cross-sectional study in the public health sector of the Western Cape, South Africa. J Health Inform Afr. 2024;11(2):1-16.
- National Department of Health, Republic of South Africa. Annual report 2024/25. Pretoria: National Department of Health; 2025.
Really insightful with real world problems that when solved, can have transformational impact.
Key learning. Lets not criticise the duct tape solutions as they have been created with good insight, knowledge and experience but lets learn how to evolve these solutions, leveraging technology and digital alternatives.
Agree completely, Sharon. Every system has path dependencies and we can’t, nor should we, simply unravel all the tape. It will take too long and, extending the analogy, everything will fall apart.