This November marks one-year since the release of the first Ritshidze State of Health report in Gauteng. The second report was released in Katlehong in the East Rand on 24 November.
Reflecting at this milestone shows the continued shortcomings in the healthcare system, the weak implementation of recommendations, and importantly the lessons that should be learnt if the public healthcare system is to pull back from complete collapse.
Data from this most recent report was collected between August and September 2021. In this report, 144 facilities were monitored with 3,200 public healthcare users and 118 Facility Managers interviewed.
It was noted that a year of COVID-19 impacted heavily on people’s regular health checks. In hard lockdowns fewer people arrived to pick up their ARVs and there were also fewer HIV and TB GeneXpert tests carried out. This left many more people undiagnosed and extended the delay in initiating people on treatment.
One of the report’s most worrying takeaways was that in Gauteng, the actual number of people living with HIV who are on treatment is a low — 65% — and only 57% of people living with HIV are virally suppressed. This low figure keeps the province from getting closer to the UNAIDS 95-95-95 targets that would see the province reach epidemic control.
A year down the line from the launch of the first State of Health report, it’s evident that there is a direct line between public healthcare users being able to easily access quality healthcare and to be treated professionally, and how this directly affects people’s health-seeking behaviour and the outcomes of whether or not they will stay on ARV treatment throughout their lives.
The report outlines the key recommendations made by Ritshidze to the provincial health department with the damning reality that now, a year later, not a single one of the recommendations made was met a year down the line.
The reality too is that many of the recommendations require more commitment than huge expenditure or major decision-making. Gettable targets include restarting adherence clubs and redirecting people living with HIV to external pick-up points for their ARVs; adding an additional few opening hours per day to clinics to ease congestion; and ensuring working people can get help after-hours. It also includes measures like making clinic grounds accessible before the clinics open as many healthcare users are forced to arrive in pre-dawn hours and have nowhere safe to wait. It’s also completing staff disciplinary hearings in a fixed timeframe; promoting a “welcoming” strategy of not shaming and shouting at those who have missed appointments or have interrupted treatment; and serving key populations (including gay, bisexual and other men who have sex with men, people who use drugs, sex workers, and trans* people) with respect and professionalism.
Much of the province’s problems — as is the case in other provinces — come down to structures and systems within the Department of Health that have become inefficient and created a repeating loop of failings. In the last reporting period the province noted that 68% of Facility Managers reported that they have staff shortages. As clinic staff come under pressure they can develop poor attitudes and suffer from low morale and burnout. It can manifest as absenteeism, poor productivity and disdain, and outright resentment and maltreatment of public healthcare users.
A woman living with HIV who spoke at the meeting told how she was given a feeble “sorry” when her child died, after what she considers to be careless treatment and poor advice from nurses. She told how her daughter was born HIV negative and was given nevirapine syrup to prevent mother to child transmission as she intended to breastfeed her child.
At her daughter’s six month immunisation clinic visit, she asked nurses to continue giving her nevirapine as she was going to continue breastfeeding her child. They told her it was unnecessary so long as she continued with her treatment, which she did.
But three months later her child fell ill and had to be admitted to hospital. It was then that she was told her child had HIV. A short time after her daughter died.
When she later returned to tell the nursing staff all they could offer was a “sorry” and that they would write a report. “I will hate them at that clinic forever,” she said at the meeting.
Another two clear cases of utter lack of respect for people living with HIV was highlighted by two women who told how nurses unethically disclosed their HIV statuses without their consent leaving them the target of threats and harassment (you can read their stories in the sidebar below).
The report also outlined how Gauteng Department of Health infrastructure is not keeping up with its expanding citizens. At least 78% of facilities reported that they needed more space; 59% of facilities have toilets in bad condition; and 47% of facilities don’t have enough waiting room.
There is also an increasing one-size-fits all formula in treating public healthcare users, it seems. Individuals’ specific medical and healthcare needs are not taken into account. Community members who spoke out during the report back meeting complained that their medication is changed without adequate explanations. Sometimes general painkillers are given to people as a cure-all. People also felt they could not raise their complaints and many left the facilities without any help or medication.
One young woman who spoke at the meeting, said that she approached her local clinic asking them for contraceptives. “I know my rights so I asked them to open a card for family planning for me because I wanted to protect myself because I was sexually active. They told me I was too young and told me to go home. I later became pregnant. I didn’t finish my schooling, I have a child and I don’t have a job — I won’t forgive them for what they did to me,” she said.
A 27-year-old man born with HIV said that during the COVID-19 lockdowns last year he wasn’t allowed into his Soweto Clinic to collect his ARVs. People were simply handed medication in brown paper bags. When he opened his bag at home he realised his medication had been changed.
“I figured the nurses know best; though no one explained to me the side effects,” he said.
Two weeks later he suffered severe diarrhoea and had to be hospitalised.
“I (stopped treatment) for two months because I didn’t want to carry on taking that medicine. When I went back to the clinic they didn’t want to hear my story even when I told them that taking that medicine they gave was putting my life in danger,” he said.
The community meeting in Katlehong was attended by a number of Department of Health programme managers and district officials from across the province. Many who spoke on the day expressed that hearing from public healthcare users was eye-opening and committed to reviewing the recommendations in their respective departments.
The officials pointed out, however, that given the structure of government (essentially operating in silos) that Ritshidze’s recommendations had to be directed to specific programmes, districts and departments for any real impact that can drive change.
Two women who live in Pretoria North who both use the Stanza Bopape Clinic in Mamelodi gave emotional accounts of the horrendous consequences of nurses who act with malice and without regard for the safety of people living with HIV.
They share the same terrible betrayal by nurses at the clinic that they say uncaringly disclosed their HIV status to their sexual partners leaving them vulnerable to harassment and threats and also caused relationships to end.
Responsible index testing — where healthcare providers reach out to the contacts of people living with HIV for testing — is one strategy to find more people living with HIV. But nurses who force people living with HIV to give contacts, and fail to follow basic procedures to screen the risk of violence and act professionally or with correct discretion, are creating risks — disclosing people’s HIV status without consent, adding to the crisis of gender based violence in the country, and denting confidence in the public healthcare service.
In the first instance Thandi*, who is now 38, tells how in 2013 she was diagnosed with HIV and initiated on treatment. But by 2015 she quit “because it’s the way the nurses treat you at the clinic”, she says.
It started with being separated from general patients as someone living with HIV in clinic queues. Then it was having nurses announce to everyone in the waiting area that she was at the clinic for HIV.
“Even when I left the clinic she would shout from behind me so everyone could hear “don’t forget to take condoms and use them,” she says.
Since then Thandi has been on and off treatment but finally decided to to restart treatment in 2020 at Stanza Bopape.
“The nurse was friendly at first because she knew me from when I dated a guy who lives on the same street as her. I told her we were not together anymore and that I didn’t even have his phone number anymore and just left it like that,” she says.
But days later this ex-boyfriend stormed into her house screaming and swearing at her and creating a commotion on her street intending for her neighbours to hear.
“It was very hurtful; he threatened me and told me the nurse had told so he knew it was true. He started following me and shouting and screaming at me on the streets. Eventually I had to go to the police. But that nurse, I could never report her to anyone. I wish I could ask her why she did that; why didn’t she find a better way to tell him?” she says.
For Sibongile*, the indiscretion and unethical actions of another nurse at the same clinic led to her relationship ending. She was threatened by this boyfriend and then he broke things off.
Sibongile who is in her early 40s was diagnosed with HIV in 2013. For seven years there were “problems here and there” at the clinic but nothing that has enraged her as much as what happened in 2020. She was ambushed into index testing of a man she had just started seeing at the time.
“I told the nurse that I hadn’t told my boyfriend about my HIV status yet because the relationship was very new. I told her I would tell him myself when the time was right.”
“She told me to give me his number anyway and I trusted her when she said it was just to call him to talk about testing and that my name wouldn’t come up,” she says.
But two days later her boyfriend confronted her screaming, swearing and threatening to kill her, saying she had put his life at risk.
“He told me the nurse had told him and that he didn’t want anything to do with me and he left me. You can’t complain about the nurses, they don’t care. I wish the nurse knew how hard it is already for someone like me to have a relationship. I’m in my 40s, I have HIV, I don’t even have a kid. It’s very difficult. I was going to tell him about my status, but just not like this,” Sibongile says.
* Names have been changed to protect people’s identity.