Yesterday Ritshidze launched a detailed report into the state of the public healthcare system in North West that finds improvement in certain indicators, and deterioration in others over the last year, impacting the overall quality of HIV, TB, and other health services. The report was presented to the North West Department of Health and other duty bearers at a community meeting in Mafikeng. You can find the presentation here and watch the full recording below.
Despite significant improvement, the stockout crisis still persists in the province. This year there were 398 reports of different medicines, contraceptives and vaccines being out of stock in total across 57 facilities, down from 895 reports across 56 facilities last year — and 26% of patients said they or someone they knew had left the facility without the medicines they needed. The North West scored worst across all provinces monitored on this indicator. In terms of staffing, 71% of facilities did not have a dedicated pharmacist or pharmacist assistant working at the facility.
Community members explained how medicine stockouts impacted them — often meaning that after waiting all day, you are sent home empty handed and told to go and buy the medication.
Waiting times have improved, down from 5:09 hours to 4:08 hours waiting after the facility opens. However, 91% of public healthcare users interviewed think that waiting times are still long. 64% of those people blamed staff shortages for the long hours waiting. While marginal improvement has been identified in staffing levels in the last year — from 0% of Facility Managers reporting enough staff last year, up to 15% this year — this remains a very high proportion of understaffed sites.
Community members explained the impact of long waiting times.
Positively the North West has some of the cleanest facilities when compared to other provinces: 77% of public healthcare users reported that clinics were “very clean” or “clean” — and only 5% of public healthcare users reported that facilities were “very dirty” or “dirty.” However, there is still inadequate space. 92% of Facility Managers interviewed reported needing more space for waiting areas, filing systems, and rooms for private HIV counselling/testing and medical care.
The North West is lagging behind in extending supply of ARVs, with just 6% of people living with HIV interviewed reporting 3 month ART refills — compared to 25% in the same reporting period last year. Extending ARV refills is an important strategy to support people living with HIV to remain on treatment as well as ease the burden on already overstretched facilities.
Another key issue revealed in the data is on people living with HIV being denied ARVs because of not having a transfer letter. Transfer letters are not required in the national adherence guidelines, yet 123 people in North West interviewed by Ritshidze had been denied access to services for not having one since we started collecting this data last October. This represents 7% of all public healthcare users interviewed, but given that most people interviewed are unlikely to have attempted to transfer services, it continues to point to a much larger problem regarding the communication and policies regarding transfer letters.
One area of improvement was an increase in the number of people living with HIV (100%) who said that a healthcare provider had explained the results of the viral load test results to them, compared to 93% in the same reporting period last year. The province remains the highest performer on this for the second year.
The next step is improving the quality of these explanations to ensure better understanding of the benefits of treatment adherence, including that an undetectable viral load means a person cannot transmit HIV — something that only 75% of people interviewed understood overall. However this challenge can be pinpointed to Dr Kenneth Kaunda district. While the majority of sites in Bojanala and Ngaka Modiri Molema had 100% agreement with these statements, most people living with HIV in Dr Kenneth Kaunda were unable to correctly answer these questions, pointing to possible challenges with how viral load test results are being explained in the district.
For key populations, many additional barriers persist in accessing health services. Staff can be unfriendly or openly hostile — only 33% of respondents reported that facility staff are always friendly and professional towards gay, bisexual and other men who have sex with men; 35% towards people who use drugs; 33% towards sex workers; and 40% towards trans* people. This drives key populations away from accessing critical HIV, TB, STI and other health services.
Where key populations do continue to use the public health system, specific services remain unavailable. Only 20% of gay, bisexual and other men who have sex with men, 9% of people who use drugs, 14% of sex workers, and 14% of trans* people reported being offered PrEP at the facility; and only 9% of gay, bisexual and other men who have sex with men, 12% of people who use drugs, 5% of sex workers, and 4% of trans* people said they could access lubricants. Some community members even explained how healthcare workers say they should use vaseline, an oil based lubricant that the World Health Organization warns against using as it can damage latex condoms putting people at risk.
This is just a snap shot of the issues discussed in the community 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 North West 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.