Last week Ritshidze launched a detailed report into the state of the public healthcare system in the Free State. The report was based on the results of data collected through Ritshidze’s community-led monitoring. It was presented to the at a community accountability meeting in Batho, outside Bloemfontein. You can read the summary presentation here and watch the full recording below.
COVID-19 has worsened healthcare in the province. In 2020, as with other provinces, there was a decline in the overall number of visits to health facilities in the Free State compared to previous years, a result of the COVID-19 pandemic, and fewer HIV tests were carried out in the province. Similar is true for TB, with a decline in the number of GeneXpert tests carried out. Fewer people getting tested for HIV and TB will lead to an increase in the number of people with undiagnosed HIV or TB, and add to those not yet initiated on treatment.
Ritshidze observations and data collected from interviews with patients and staff highlighted challenges due to COVID-19 in the preceding three months including: longer waiting times, less staff working than usual, and the clinic not being open when they needed it, increased stockouts, people not being able to get transport when needed, and a lack of safety precautions at some facilities including no physical distancing and a lack of availability of water/soap or sanitizer at the clinic.
UNAIDS’s scaled up targets now aim for 95% of people living with HIV to know their HIV status; 95% of people who know their status on treatment; and 95% of people on treatment to have suppressed viral loads. Yet in the Free State, while 91% of people living with HIV know their status, only 81% of those people are on HIV treatment, out of which 89% are virally suppressed. Ritshidze data points to many challenges at the clinic level that mean many people living with HIV either never start treatment, or are pushed to stop.
Understaffed clinics mean healthcare workers are overburdened. This leads to longer waiting times, limited time to attend to patients, and at times, bad attitudes. These factors directly contribute to PLHIV starting and staying on treatment and can be linked to the province only attaining 81% of PLHIV who know their status on treatment.
Early mornings, feeling unsafe outside the clinic, and long waiting times cause people to dread clinic days or even stop going. In the Free State public healthcare users reported that they spent an average of 5.36 hours waiting in the facility. The average was five hours or more at 15 of those clinics, and four hours or more at 19 clinics. This is a very long time to spend at a facility in which patients are usually only seen for a very short consultation.
Toilet cleanliness also remains a significant problem. 60% of Ritshidze observations found that toilets were in bad condition, with very slight variation amongst districts, with 67% of toilets in bad condition in Lejweleputswa, 50% in Mangaung, and 50% in Thabo Mofutsanyana. The biggest concerns were around there being no toilet paper, no soap, and no water at all.
One woman explained that while the clinic is usually tidy and facilities and the toilets do work, by the middle of the day the toilets start to get dirty and are not cleaned regularly enough and toilet paper runs out and is not replaced. “It must be at a standard and it should be hygienic. We are talking about a clinic where there are sick people and you don’t want people to make each other sick,” Nonhlanha said.
Unnecessary trips to the clinic just to collect an ARV refill adds both a burden on people living with HIV and to the already overwhelmed clinic and healthcare worker staff. This inefficiency can also contribute to people living with HIV disengaging from care directly impacting the province’s attainment of 95% of PLHIV on treatment. Extending treatment refills, also known as providing “multi-month dispensing” or MMD, is one strategy to reduce unnecessary burdens and support both people living with HIV and the health system to be more efficient. However Ritshidze data reveals that just 6% of PLHIV reported 3 month ART refills. Further, 26% of PLHIV still reported refills of 1 month or less. Free State is in fact performing the second worst across all provinces in regard to length of ARV refill, with only Limpopo performing worse.
Positively, 100% of Facility Managers said they were giving 12 month scripts for stable PLHIV, as outlined in a government gazette on 12 month ART scripting in 2020. We hope this is indicative of all facilities across the province.
Long waiting times and frequent trips to the clinic place an unnecessary burden on PLHIV, health facilities and healthcare workers, directly impacting the province’s ability to get 95% of PLHIV on treatment and 95% of PLHIV virally suppressed. Repeat prescription collection strategies should simplify and adapt HIV services across the cascade, in ways that both serve the needs of PLHIV better and reduce unnecessary burdens on the health system In order to be most effective, repeat prescription collection strategies should make ARV collection quicker, easier and more satisfactory for PLHIV, of which Ritshidze data found they do. Out of 70 PLHIV interviewed using External Pick up Points, 100% thought they made ARV collection quicker — and the majority of PLHIV were either satisfied or very satisfied with them. Given the high satisfaction rates, it is important to ensure that as many stable PLHIV as possible are enrolled in a repeat prescription strategy.
People living with HIV lead complicated lives and may miss appointments and even miss taking some pills. When they do, meeting them with support when they return to the clinic helps ensure long term adherence. But those who return to the clinic and are treated badly, or who fear they will be, will often not come back.
One significant barrier to access HIV services for key populations like sex workers, transgender people, people who use drugs or men who have sex with men, is being discriminated against at the facility. For key populations to receive quality services, they need spaces that are safe enough to disclose that they are key populations without fear of poor attitude, discrimination and/or arrest. Yet staff are not sensitised at primary healthcare facilities — the entry point for most key populations to access HIV, TB, and other health services — to provide key population friendly services. At times key populations can be shouted at or even chased away from the clinic without getting the services needed.
This is just a snap shot of the issues discussed in the community accountability meeting. It was a space for public health users to talk directly to those in power. Community members reported their challenges and sought rapid interventions by the Free State Department of Health and PEPFAR implementing partners in the province. Follow Ritshidze on twitter, facebook and instagram for regular updates or go to www.ritshidze.org.za for more.
