Last week Ritshidze launched a detailed report into the state of the public healthcare system in Limpopo. 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 Seshego, outside Polokwane. You can read the summary presentation here and watch the full recording below.
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 Limpopo, while 91% of people living with HIV know their status, only 73% of those people are on HIV treatment, out of which 87% 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.
One of these challenges is the shortage of staff in our clinics. This leads to a litany of further issues including longer waiting times, overburdened healthcare workers with limited time to really attend to patients and provide them with the consultations and information they need, and even at times, patents facing bad attitudes from staff at the facility. These factors directly contribute to whether people living with HIV start and importantly stay on treatment and can be linked to the province only attaining 73% of people living with HIV who know their status on treatment.
One community member told us, “just to go there to pick up your medicines means you can wait an hour or more at each queue,” he said, adding that there have been occasions when he’s just been told to come back on another day once he’s got to the front of the queue. “It’s frustrating”, he said that the clinic staff don’t understand that when they can’t operate efficiently it affects patients’ entire days. “You can also get there and then they can’t find your file and you have to sit and wait again,” he said. He told us that clinics also need to move more rapidly to put more stable patients on systems like external medicine pick-ups – it would suit working people like him he says and those who feel too stigmatised to be in the clinic.
Another challenge is stockouts and shortages of medicines. At times healthcare users can disengage from care, seeing no point in going to the clinic to be sent home empty handed (as reported in 50% of sites that were facing a stockout). No-one should be sent home empty handed from the facility, forcing them to interrupt treatment.
Toilet cleanliness also remains a significant problem. 74% of Ritshidze observations found that toilets were in bad condition — 60% of toilets in bad condition in Capricorn, 100% in Mopani, and 63% in Vhembe. The biggest concerns were around there being no toilet paper, no soap, no water, no light, or that toilets were dirty.
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 currently, Limpopo is performing worst out of all provinces in the length of ARV refills, with 46.4% of people getting 1 month or less.
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. This directly impacts our ability to reach the 2nd and 3rd 95 targets.
One community member explained that because she was young when they found out she was HIV positive, “the nurses judge me when I go there. They don’t treat me like a human being and I never asked to get HIV,” she said. It seems nurses find any excuse to bully patients like her she added. “They are always shouting at the patients and even if you come there by 7am and they know you are only going there to collect medicine they won’t help you. They let you sit there till 3pm or 4pm.” She said that the few times she’s been unable to make her collection dates she’s literally blasted and screamed at like a misbehaving child. “They make me want to default – they don’t want to hear that I had a problem coming to the clinic on that day,” she said.
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
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 Limpopo 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.