Free State, 31 October 2025 – Between April and June 2025, a team at the Treatment Action Campaign (TAC) began monitoring through Ritshidze to assess the state of clinics in the Free State. During the three months we carried out 5,543 surveys with public healthcare users, and spoke to facility staff to assess 57 facilities in 3 districts in the province. The data reveal major shortfalls in the quality of health services being delivered in the province – outlined fully in the 5th edition of the Ritshidze State of Health report for the Free State.
Critical staffing shortages were reported. 72% of people said there were never enough staff in the clinic – by far the most reports out of all six provinces monitored by Ritshidze. One person living with HIV told us: “Even when you are sick and come across a busy nurse, they won’t assist you. There is a shortage of nurses at the clinic”.
Only 6% of people said there were always enough staff in the province. “I went to collect my ARVs in April 2025. I was told to come back in May because there were no nurses at the clinic.. I had run out of ARVs and went home empty handed. The same thing happened in May.. There were no nurses, and the queue was long with many patients coming to get their medication,” another person living with HIV went on to say.
The consequence of the staffing crisis is lengthy delays at the clinic. Public healthcare users waste hours in long queues for check-ups, or even just to collect medication. The Free State had the longest waiting times out of all six provinces monitored by Ritshidze at 5:25 hours – with Mangaung close to 7 hours. “You wait from the morning until late at 4:30pm. You spend the whole day on your feet,” one community member told us.
89% of people said the waiting times at the facility are long. This was particularly severe in Lejweleputswa where 90% of people thought the delays were long, and Mangaung where shockingly 99% – almost everyone – thought so. Again the Free State performed worst on this indicator.
One person living with HIV explained: “I have to take a day off from work and go spend my time in the queue for treatment”. Another person living with HIV described his frustrations: “You can arrive at the clinic at 8am, but only receive your treatment after lunch, around 1:30pm. This is very frustrating and painful to experience regularly”.
Those who do not arrive early enough risk being sent home empty handed. “I arrive between 5am and 6am to avoid being turned away without being assisted,” one community member explained to us. Another complained how: “I only got home at 4pm, without receiving enough treatment. I was told to come back again the next day.. Sometimes it feels better to just stay home rather than go to the clinic”. These are core factors why people feel forced to arrive at the crack of dawn, and why waiting times calculated from when people actually arrive must not be disregarded. (Note Ritshidze calculates and reports waiting times in two ways: 1) from when the clinic actually opens, and 2) from when patients arrive – the latter being a common source of contention from health officials, despite the lived reality of public healthcare users).
Disorganised clinic filing systems also contribute to delays when files pile up waiting to be captured or refiled, and there are too few hands to keep up. While Thabo Mofutsanyana has done well to maintain their filing systems, Lejweleputswa still needs attention with 35% of filing systems observed in a bad condition. Mangaung’s filing systems are reported to be in a disastrous state with 80% in a bad condition. “It takes a long time to get your clinic file from reception.. Sometimes files even go missing, and you don’t know what happened to them. When that happens, they make you go inside the room to look for your file yourself,” a community member explained.
70% of people said it took over one hour just to receive their file – 42% of whom said it took over two hours. This compares to just 3% who said it took over one hour in KwaZulu-Natal. The Free State had the longest waits for people to receive their files by far. One person living with HIV described how “it can take up to 4 hours for them to locate my file and this causes trouble for me at my work. I get angry when I think about the long waiting times and how this can end up affecting my job”. Another community member told us: “when your file isn’t found, then they will ask you to book another date as if it is your fault.. I no longer like going to this clinic. [Last time] I arrived at 7am and left the clinic at 4pm. I spent the whole day there”.
90% of people blamed the longer waits than usual on disorderly filing systems and their files getting lost. This was particularly severe in Mangaung, where 99% of people raised this issue. “I arrived at 5am and waited for my file for a long time.. The nurses looked for my file until 3pm.. eventually they told me that I did not appear on the system. They couldn’t find my file. I was sent home without ARVs because of the missing file,” explained one person living with HIV. Another said:
“I went to the clinic as usual to collect my ARVs and was turned away as they could not find my file. I went again to the clinic after a week, but still did not get my medication due to my file being lost. I was told they can not access my information. I am angry and worried about my health. I might not go back to the clinic”.
When queues stretch beyond two to three hours and files take an hour or more to find, people give up and leave – interrupting treatment, risking disengagement, and facing harsh treatment when they return after missing an appointment. “I stopped going to the clinic to collect my ARVs.. I got tired of the long waiting time. It was frustrating to have to wait almost the whole day at the clinic just for ARVs. I ended up deciding to stay at home without medication,” a person living with HIV explained.
An easy solution to reduce congestion and long delays is to get people out of the clinic who do not need ongoing clinical care. This can be done by giving out longer medicine supplies and letting people collect ARVs at quicker collection points.
In early 2024, the Free State had fallen far behind other provinces in giving people living with HIV longer ARV refills. Following pressure by the Treatment Action Campaign (TAC), a commendable turnaround took place. On the day of monitoring, 96% of people reported getting a 3 month supply or longer in Lejweleputswa – putting the district among the top four best performing districts out of all 16 monitored by Ritshidze. Thabo Mofutsanyana still has a way to go at 77%, but this is a vast improvement from 17% in 2024 when TAC took to the streets and began engaging with the district.
However in Mangaung only 13% of people reported getting a 3 month supply or longer. One person living with HIV in the district said: “They only give me a 1 month supply of ARVs. Every month they give us treatment”. Another went on to say: “I went to the clinic to collect my ARVs. I was sent back home without my medication and was told to go to the National Hospital to fetch it there as there was no stock at the clinic”. Mangaung was the worst performing district out of all 16 monitored by Ritshidze in providing longer refills.
On top of this, the health department should be rolling out 6 month supply. “If I could get a 6 month supply, I’d be very happy.. The queue is always long, it’s always packed, and there are always people from the previous day who didn’t get help coming back the next day. A 6 month supply can really reduce people going there all the time,” one person living with HIV told us. Another said: “I would like to get a 6 month supply so I won’t have to go to the clinic as often. There will be more space then, for people who actually need to consult.. there would be less congestion at the clinic”. Yet by the end of September, only 640 people had been enrolled.
One in five people still reported having to see a clinician every time they need to collect their ARVs, with 83% saying they have never been offered the option to use a pick-up point. “I get my ARVs at the clinic.. but there are so many of us, they can’t treat us at one time,” one person described.
54% of people surveyed said it took longer to collect their parcel than before the end of January 2025.
“Since January, I have noticed changes. They used to deliver my treatment at home but I ended up having to go back to the clinic, where I waited for a long time. Close to 4 hours. It’s challenging when we have to register and retrieve files. They are slow,” one person living with HIV told us. Another explained: “I used to collect my ARVs at an external pick-up-point. But I was told to go back to the clinic. The external pick-up point made things very easy for us. The clinic waiting times are very long, and sometimes we have to go back home without being seen and come back on the following day. There are a lot of people back from external pick-up points, and none of us understands why”.
Since the PEPFAR disruptions, 31% more people surveyed reported that staff were unfriendly compared to January 2025. One community member said: “The nurses are not friendly at all, they shout at us so much that is why I decided not to go there anymore”. Another person living with HIV recounted being sent home without ARVs: “The nurse who is on duty is sometimes rude, saying that if we are slow, she will leave us. She will not be joking.. You end up not getting treatment. I once spent 3 days without treatment. They are risking people’s lives”.
Shockingly, only 2% of people said staff were always friendly in Mangaung. The Free State had the most unfriendly staff out of all six provinces monitored by Ritshidze, with Mangaung the least friendly. Understaffed clinics are placing added pressure on already overstretched nurses – fueling frustration and making unfriendliness and poor service more common. Public healthcare users are left to face long waits and unfriendly staff. “It is discouraging to be treated disrespectfully when seeking essential services.. but we continue to go to the clinic because we need services and cannot afford private healthcare,” another community member explained.
People living with HIV are routinely punished in the province. “If you miss your appointment, they help you last or give you another appointment date. They don’t care if you have treatment to last until the next appointment date. This is how they operate. It is not new. They do not want to understand the reasons behind us missing our appointment dates. We have to work to afford food, to be able to take our medication properly. Those are some of the reasons why we miss appointment dates,” one person living with HIV told us.
Instead of health workers making it easier for people to keep collecting their treatment – as reported by just 2% of people who had been late for or missed an appointment surveyed in the Free State – 33% said staff shouted at them on return in Mangaung, 30% in Thabo Mofutsanyana, and 16% in Lejweleputswa. The Free State accounted for 37% of the 512 people who reported being shouted at across all six provinces monitored by Ritshidze – as described by one person living with HIV: “When we miss appointment dates, they shout at us.. I always tell them that we are people too and we sometimes have things to do.. Maybe you are going to an interview or you have to attend meetings at school as a parent you can’t miss”.
Others reported being sent to the back of the queue to wait until all other patients had been seen as a punishment – including 83% of people surveyed in Mangaung, 55% in Thabo Mofutsanyana, and 47% in Lejweleputswa. The Free State accounted for 54% of the 877 people who reported being made to wait across all six provinces monitored by Ritshidze.
One person living with HIV reported: “When you miss an appointment, they don’t help you.. Missing an appointment means not getting help or being pushed to the end of the line, even if you came first”. Another described how: “If I miss an appointment, they will shout at me and then send me to the back of the queue, saying they’re helping people for that day. They’ll only help you at the end of the day. Sometimes you’ll have to leave without assistance, and then you must come back again”. Yet the guidelines specifically state that no punitive actions are allowed.
Members of key populations in particular continue to be treated poorly in our clinics. “The staff sometimes tell me that I am dirty and that I smell bad, which is very hurtful. This makes me afraid to use the clinic.. The staff members are very rude,” one sex worker told us. A trans woman explained the pain trans people face at the clinic: “Cases where transgender people have been raped and then must explain themselves to multiple nurses at the same time are completely unacceptable. This is one reason why many transgender people avoid using such services, as it is humiliating and degrading”.
Only 60% of trans people, 57% of gay, bisexual, and other men who have sex with men (GBMSM), 49% of sex workers, and 33% of people who use drugs reported that staff were always friendly in our last data collection. One gay man explained the discrimination he faces each time he goes to the clinic: “Some nurses stigmatise me, calling me “tsala” – a derogatory term in Sesotho used for gay people. They do this openly in front of other patients in the waiting area. I have told them multiple times to stop because it’s painful and humiliating, but they continue using this name”. A sex worker we spoke to reveals how the poor treatment puts people off going to the clinic altogether: “the staff gossip about our medical history.. How can they ask us about our health issues in front of other patients? This is why many of us stop taking our treatment because of the way we are treated and the invasive questions we get from the staff.. These gossips and the constant judgment make us afraid to go to the clinic”.
Members of key populations had also been refused access to health services. 8% of GBMSM, 11% of sex workers, 14% of trans people, and 26% of people who use drugs surveyed in the Free State had been denied services in the last year, and 8% of people who use drugs had been denied their ARVs. “The staff don’t even ask what services you need or explain the services they offer. They just listen to what you say you came for, and then send you away,” a sex worker explained to us.
It is not only ARVs. 11% of people surveyed had been told they could not get PEP at the facility – pills to take after HIV exposure to stop you getting HIV – specifically because they are trans, and 20% because they are a sex worker. 17% of people surveyed had been told they could not get STI services at the facility because they are a sex worker, 25% because they are GBMSM, and 27% because they are trans. A gay man revealed: “Nurses make excuses to avoid providing services, saying there are stockouts, or that the pharmacist or STI nurse is unavailable. Sometimes they say the HTS counsellor for HIV testing isn’t there. I believe these are just excuses because this happens too often”.
Contraceptives were also denied with 16% of people surveyed being denied contraceptives because they are a sex worker, 40% because they are trans, and 48% because they use drugs. One trans person explained how the lack of gender affirming care at the clinic impacts them: “It makes us feel as if we are not human.. Sometimes we feel like we don’t want to go to the clinic.. Using the clinic lowers our confidence and self-esteem”.
Changing between clinics remains a nightmare. 240 people reported having been denied services because they did not have a transfer letter in the last 3 months in the Free State – something that is not required by national ART guidelines to start or restart your ARVs. One person told us: “I went to the clinic to ask for a transfer letter, and the admin clerk refused. I needed the letter so that I could collect my ARVs. I then decided to go to [my new clinic] without a transfer letter, but they refused to give me my ARVs.. I was told to go back to my previous clinic and come with a transfer letter”.
The Free State accounted for 76% of the reports across all six provinces monitored by Ritshidze – the majority originating in Mangaung. People who are unable to collect these transfer documents are very likely not to return and stop treatment, as explained by another community member: “I have not been taking my ARVs for about 3 years. I moved and went to [a new clinic], but the sister on duty told me that they were not going to help me without a transfer letter. I told them that I did not have money to go and get it from the facility I was using. I stopped going to the facility until today”.
On top of this, 489 people told us they or someone they knew had been denied services without an ID – including 96 people in Lejweleputswa and 374 people in Mangaung. The Free State accounted for 74% of the 665 people who reported this across all six provinces monitored by Ritshidze. 51 people had been denied services for not being South African. The Free State was the worst offender for turning people away for these reasons.
While the South African public health system is under strain, scapegoating migrants diverts attention away from the real challenges – decreasing budgets and lack of investment, the withdrawal of PEPFAR resources, overworked healthcare workers, mismanagement, corruption – that have plagued the public health system. Denying migrants health services does not alleviate this crisis. Furthermore, an estimated 12% of people born in South Africa do not have identity documentation.
HIV prevention has also been impacted. Only 76% of sites in Lejweleputswa had external condoms available – 24% of facilities not providing external condoms is unacceptable as the provision of condoms is known to be the cheapest and most cost effective HIV prevention intervention. Only 29% of sites had internal condoms in Lejweleputswa, and just 40% in Thabo Mofutsanyana. Only 18% had lubricants available in Lejweleputswa, and just 65% in Mangaung. “There are no lubricants available at the clinic. It has been two years since we last had any,” one sex worker told us.
These commodities are the basics of the HIV response and should be easily available to take without question or judgement at all sites. “Condoms and lubricants are not displayed in the distribution box, so I have to ask for them whenever I need them.. it makes me feel ashamed because I have to ask instead of taking them freely,” one trans woman explained.
While PEPFAR was not procuring these commodities, ensuring they were easily available to take at clinics was likely part of their role. On top of this 74% of PrEP users said it took longer than usual to collect PrEP (pills to take before an HIV exposure to stop you getting HIV), 13% said there was no PrEP available, 8% had to return because of the queues, and 7% said they were given a smaller supply. “I needed PrEP, but I was told it wasn’t available and was asked to come back after a few days. However, when I returned, it was still not available,” one person told us.
While the data reveal some positives in the Free State, the low quality of health services being provided is undeniable. This must not be ignored as the Department of Health aims to get 1.1 million more people on, or back on, HIV treatment – including those who have disengaged because of poor conditions at the clinic.
Ritshidze is particularly concerned by the poor quality of services in Mangaung, where waiting times were among the worst recorded, filing systems were in complete disarray, and staffing shortages were acute. This is one of the country’s high HIV burden districts that has never received PEPFAR support – offering a clear picture of what the long-term absence of that support looks like. The situation in Mangaung is a warning. PEPFAR support clearly contributed to better outcomes in other districts, and without urgent action, gaps left behind will deepen inequalities. High burden districts like Mangaung must receive the staff, systems, and support they need. We call for special monitoring of the situation in Mangaung at both the national and provincial levels.
For more information or to arrange interviews contact:
Ngqabutho Mpofu | +27 72 225 9675 | ngqabutho.mpofu@tac.org.za
Lotti Rutter | +27 82 065 5842 | lotti@healthgap.org
Notes:
The Free State, State of Health report is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-State-of-Health-Free-State-2025.pdf
A summary presentation is available here: https://ritshidze.org.za/wp-content/uploads/2025/10/Ritshidze-Free-State-State-of-Health-October-2025.pdf
What is Ritshidze?
Ritshidze is a community-led monitoring (CLM) system implemented by the Treatment Action Campaign (TAC). Through Ritshidze, community members systematically collect data at clinics and in the community that are analysed, and then used to generate solutions to problems that are put to duty bearers for action. Community-led monitoring is an indispensable strategy for improving the state of our public healthcare system, and getting more people on ARVs.
How does Ritshidze collect data?
Ritshidze collects both quantitative and qualitative data through observations, as well as through the implementation of standardised surveys and in depth interviews with healthcare users (public healthcare users, people living with HIV, members of key populations) and healthcare providers (Facility Managers, pharmacists/pharmacist assistants). All Ritshidze’s data collection tools, our data dashboard, and all raw data are available through our website.
What changes have been made in where Ritshidze collects data following the PEPFAR disruptions?
Since inception, Ritshidze data has been consistently collected across sites in the two PEPFAR priority districts in the Free State: Lejweleputswa and Thabo Mofutsanyana. While Ritshidze monitoring will continue in these districts, PEPFAR implementing partners have now had their contracts terminated in both districts – the province is no longer receiving PEPFAR support. Ritshidze data will be able to document any changes in the quality of service provision following the PEPFAR withdrawal. From this reporting period, Ritshidze data will also be collected in Mangaung, a non-PEPFAR priority district. By moving beyond only monitoring PEPFAR priority districts, Ritshidze aims to understand the quality of service provision in the next layer of high demand/high burden districts.
What changes were made to data collection to determine the impact of PEPFAR funding cuts on HIV services?
A new tool was developed in this reporting period to survey patients as they exit the clinic. This was to gather evidence to the state of service provision that day – to better understand the impact of the PEPFAR disruptions on clinics. All monitoring tools are available here: https://ritshidze.org.za/category/tools/
Data collection periods and locations
Facility level data was collected between April 2025 and June 2025 at 57 public health facilities in three districts: Lejweleputswa (17 sites), Mangaung (20 sites), and Thabo Mofutsanyana (20 sites). Surveys were carried out with 57 Facility Managers, 3,021 public healthcare users and 1,503 people living with HIV in the Patient survey, and 2,522 public healthcare users in the Patient Exit survey.
Key Population service data was collected in the community between July 2024 and September 2024 in three districts in the Free State: Lejweleputswa, Mangaung, and Thabo Mofutsanyana. A total of 1,551 surveys were carried out in the province (including 1,377 people using public health facilities). This combined 420 gay, bisexual, and other men who have sex with men (GBMSM), 594 people who use drugs, 219 sex workers, and 144 trans people.