When ambulances don’t turn up in emergencies; when nurses shame sex workers for taking “too many” condoms; or when people who have defaulted on treatment aren’t welcomed back to care – these are blows to public confidence in the healthcare system;  they can also determine the difference between life and death.

The brutal realities of having to depend on a poorly functioning clinic system and healthcare services was heard loud and clear when community members spoke at the September 23 launch of the Ritshidze Eastern Cape State of Health report. The 49 clinics and healthcare facilities monitored in the province are in OR Tambo, Buffalo City, Alfred Nzo, Amathole, Nelson Mandela Bay, and Chris Hani.

Among those who told their stories at the East London launch was a woman who lost two brothers to AIDS. Both brothers, she said, had defaulted on treatment but did not feel welcome or supported to restart treatment at their clinic.

“It is not HIV that is killing our people, it is the ill treatment of our people, like my brothers, that is making them to default and for them to die,” she said.

The woman, who spoke anonymously, also told of her own treatment at her local clinic and how an altercation led to the police having to be called to calm the situation.

According to her, she was shouted at and insulted when she refused to disclose why she was at the clinic.

“I believe in confidentiality and said I wasn’t comfortable to say in front of everyone why I was at the clinic. I was told that everyone before me did so I also had to. Then I was told ‘We won’t open the clinic for you. You are not special’,” she said.

Another woman told about her grandmother dying while her family waited for an ambulance in the Flagstaff area. They were subjected to numerous unfulfilled promises. The elderly woman, who had collapsed, died and the ambulance only arrived many hours later when a mortuary van was collecting her mortal remains.

Another woman was forced to relive her deep trauma but wanted to recount the story of how she and her child were treated at the hands of bullying nurses. The woman and her child were both diagnosed with HIV. While both were initiated on treatment they defaulted from treatment at one point. Subsequent complications led to her child succumbing to the disease and dying in 2018.

Instead of supporting her through her grief though, she was told by nurses at her clinic that she didn’t look after her child properly and also that ‘the same thing will happen to me’.

It put her off returning to the clinic. She also didn’t restart ART until a community activist from the Treatment Action Campaign (TAC) encouraged her to get back on her ARVs.

Poor staff attitude was outlined at the launch as “being spoken to like a child or someone who is mentally unwell”, “carelessness” and a “lack of professionalism”. Staff attitudes showed up in the report as one of the key reasons people are discouraged from using their clinics to get medical help.

Ritshidze monitors also noted that at the 49 Eastern Cape clinics and community healthcare centres monitored in the last quarter as part of Ritshidze’s countrywide clinic monitoring programme, there was still a high number of patients reporting that they were shouted at by nurses or sent to the back of the queue as punishment for missing an appointment.

Adding to tensions between nurses and patients are the fact that of the 1207 patients interviewed in the latest report, around 71% of patients said there was not enough staff at their clinics. The most critical staff shortages are of professional nurses, enrolled nurses, cleaning staff, doctors and enrolled nurse assistants.

It impacts waiting times that on average stretch to more than four hours at more than half the clinics monitored. People also reported having to arrive as early as 5.30am to try to be at the front of queues out of fear that they would be sent home without assistance on the days of their appointments.

Ritshidze recommendations and timeframes are for the Eastern Cape Department of Health to fill 80% of vacancies in the province by March 2022. Within that same timeframe District Supporter Partners (DSPs) should also ensure all PEPFAR-supported sites have at least one male nurse and male counsellor in place, to promote the uptake of health services by men. Men continue to lag behind in seeking healthcare timeously. Ritshidze has also recommended that the Department of Health compiles and releases annual reports to accurately track staff vacancies in the province.

General Secretary of TAC Anele Yawa, who is also chief accounting officer for Ritshidze, chaired the Eastern Cape report launch. He slammed nurses and healthcare workers for failing patients with their callous unprofessionalism.

He said: “It is time to name and shame these people. We must do follow-ups as Ritshidze partners and go to these clinics and demand that we get answers from Facilities Managers. It cannot be that people have to go to another clinic as the solution – we have to take this in our own hands.”

Along with staff shortages was the dire situation of communities outgrowing their clinics. Cramped spaces and buildings in need of maintenance and cleaning were found to affect over 80% of the facilities monitored in the province. This in turn impacted on where and how filing systems and patient records can be properly kept and easily accessed to shorten waiting times. Waiting areas themselves are too small or patients are expected to wait outside facilities regardless of weather conditions.

The Eastern Cape State of Health report did however, show some pockets of good operational functioning during the latest reporting period. One of the clear positives involved external medicine pick-ups. Patients surveyed welcomed the ramping up of the system to keep people living with HIV from having to be in clinics just for medicine collections.

One of the recommendations to keep this momentum going is for the Eastern Cape Department of Health and DSPs to ensure that 60% of all PLHIV in the province are using a repeat prescription collection strategy (at least 25% of those PLHIV should be accessing treatment from an external pick up point) by March 2022.

Other positives that were recorded were that 61% of facilities had male nurses, counsellors and healthcare workers on site. This improved gender split is expected to improve men’s personal responsibility in seeking health services. Ritshidze’s community monitors also noted that 95% of PLHIV were given a viral load test in the past year even though only 79% of these people said they received an explanation of their test results.

Tracking both the positive operations, interventions and success stories along with the massive challenges and sometimes outrage failings are a way to give a fuller picture of what is happening on the ground. In identifying shortcomings honestly and in communicating and presenting these effectively there is a better chance to prioritise, strategise and implement solutions to fix the country’s clinics.

Ritshidze’s community-led monitoring spans 400 clinics across the country and remains committed to giving voice to communities at a grassroots level and hearing about the realities faced by thousands of patients on a daily basis. The data and analytics are intended to be shared with government, civil society and the public. The recommendations included in all reports set out gettable goals within a realistic timeframe. They can help direct resources appropriately and effectively, and stand as a tool to hold government and officials to account.

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