There has to be more than a hope and a prayer for the South African healthcare service. But when the launch of the Ritshidze State of Health report for the Free State opened with a plea to the gods, it was clear things have gone to hell.
“Each one of us must talk to our God, and ask them to give us power to fix the broken healthcare system and go deeper into the heart of the politicians and officials within the department. We must ask that they touch the hearts and minds of the politicians and officials so that they take decisions about healthcare services that prioritise the poor,” said Anele Yawa, General Secretary of the Treatment Action Campaign (TAC) and chief accounting officer for Ritshidze.
Yawa, who chaired the report back meeting on 9 September 2021, also noted that invited politicians had given apologies for non-attendance to the meeting. Ritshidze members had met with senior provincial health department officials two days prior to the report back meeting and Yawa said they intend to follow up on promises made during that meeting.
However, officials across many provinces have either been no-shows or just logged in virtually. Many officials and representatives have also not given substantive input or outlined any strategy to fix the clinics when they have been present. This even as the Ritshidze monitoring project is intended as a tool that will help government deliver better clinic services.
The Ritshidze community accountability meetings present the findings from clinic monitoring of over 400 clinics across the country. In the Free State, community monitors focused on 22 facilities in the province. In the period April to June 2021 they conducted interviews with 425 patients (362 being people living with HIV) and 20 Facility Managers.
The meeting heard that the Free State tracks as the worst performing in the country when it comes to waiting times. Some patients had to wait for up to seven hours to be attended to. The average waiting time is around five and half hours per visit. Ideally, patients should wait one hour 15 minutes per clinic visit in order to ensure that they have an ideal healthcare user experience.
Staff shortages and unfilled vacancies have added to the long queues at clinics. Ritshidze found that 79% of facility managers said they did not have enough staff and there are currently 26 vacancies at 20 of the clinics monitored.
Many clinics have also become too small to accommodate the daily numbers of patients in queues. In a time of COVID-19 with social distancing protocols patients also have to wait outside, regardless of the weather conditions, for hours before they are seen to. Many patients also put their safety and security at risk arriving in the early hours of the morning in the hope of being near the front of the queue. They face being attacked or robbed arriving before sunrise and when there are no security guards on duty or access to safe waiting areas.
The meeting heard from community members who also complained that even when there staff and nurses on duty they are not attended to in a coordinated manner.
“The nurses will go out of the clinic together to go for their tea and we have to wait for them to return,” one person said.
Another patient said cleaners often wander in and out of consulting rooms to talk to nurses even when patients are supposed to be having a confidential consultation.
Another patient said: “The nurses walk up and down and have a bad attitude. Some are walking around in heels like they are in a beauty contest.”
Nurses being rude, unprofessional and disinterested has been a common patient complaint. Some patients who have missed appointments or who try to restart their ARV treatments after defaulting are shouted at by nurses instead of being helped. Many are punished by being sent to the back of the queue.
Ritshidze’s findings show that in the Free State only 65% of people living with HIV are virally suppressed. Currently only about 73% of people living with HIV receive ARVs in the province.
The multiple failures in clinics in the province in this reporting period are worrying indicators that hold up the progression towards the 95-95-95 by 2030 target. This UNAIDS target announced in 2014 aims to have 95% of people with HIV diagnosed; 95% of people diagnosed on antiretroviral therapy; and for 95% of those on treatment to be virally suppressed.
Clinic services and staff who are trusted and deemed professional and efficient are essential drivers to keep people on treatment, improve health-seeking behaviours and improve health literacy.
The Free State community accountability meeting also showed that tensions between staff and patients are growing. More patients reported altercations with nurses when they are repeatedly bullied and dismissed. Most concerning is that even after these outbursts they are turned away even in emergencies.
One man told his story at the meeting. He said his sister-in-law died in 2017 because of “negligence, pride and bad attitudes from nurses”. He told of how his sister-in-law was shunted between hospitals and clinics and refused help when she didn’t have a referral letter.
The woman died from TB days after the clinic said her sputum test was negative. They refused to re-test or do other testing to probably diagnose her condition.
“When I asked them to please test again the nurse said to me that I was not running the clinic and that she would do things the way she wanted to do it,” he said.
The man added: “What hurt me the most is that they were inhumane. My sister-in-law did not have to die if they just helped her instead of turning her away. She now leaves behind a four-year-old and a two-year-old. They are orphans.”
TB deaths are still counted as the country’s biggest killer. The meeting heard that in 2019 a known 36,000 people in the country died of TB. TB infection control in clinics remains one of the key priority areas that community monitors assess. Ritshidze’s “traffic light” system is used to help patients follow a checklist to make sure their clinics adhere to six basic interventions. These include displaying information posters, isolating coughing patients who arrive at the clinic and keeping windows open.
In the Free State not a single clinic managed a green status that indicates full adherence. Thirteen clinics failed with a red status and nine had a yellow status, which meant they partially met the recommended interventions for good TB control.
Patients also reported to community monitors that they have no way to complain or to raise their issues at clinic level. There is no recourse, feedback or even acknowledgement of their complaints, they said.
“The nurses tell us they are the ones who open those suggestion boxes in the clinics, so they know all that we say, so complaining is just useless, they won’t do anything,” one person said at the meeting.
In response to this, Yawa said Ritshidze and TAC would look into setting up complaints tables outside clinics to record stories and to take up legitimate complaints independently and immediately as patients leave a facility.
Yawa added: “We must demand to be included in clinic committees and we must demand that we are there when clinics open complaints boxes. We did not fight to be third-class citizens in our own country and we cannot normalise the violation of our people.”