Staff attitude – it’s the one thing that has to be addressed immediately to improve the experience of hundreds who rely on clinic services in the Mpumalanga province.

This was clear at the Ritshidze community accountability meeting and report back on the state of health in the province held in Ermelo at the end of May. The meetings that have been held in various provinces are a way to relay the data and findings from community-led monitoring of 400 clinics in South Africa. But importantly, these are platforms to use findings and evidenced insights to hold authorities to account and to compel them to act.

The issue of poor staff attitude became the common thread at the Mpumalanga meeting as community member after community member stepped forward on the day to share their stories and experiences. Despite nine key topics raised on the day, many healthcare users circled back to how interaction with staff — clinical and non-clinical — made their appointment dates something they faced with frustration, anger and dread.

The way patients are treated and made to feel by some nursing sisters, healthcare workers and even security guards, amounts to an attack on patients’ dignity. It erodes professionalism for the nursing service and tears at the already frayed trust relationship between patients and the public health service.

Most concerning is that it is becoming increasingly clear that poor quality services in the public sector creates enough of a barrier to discourage people from seeking medical help. This is a key obstacle in reaching the UN testing and treatment targets of 95-95-95 to end the AIDS epidemic by the end of the decade.

Dumi Nkosi, Director of HIV, AIDS and STIs for the Mpumalanga Health Department, was in attendance representing the government at the accountability meeting held in Ermelo.

Speaking to Ritshidze after the meeting he acknowledged that his key takeaway was that staff attitude had become the most damaging failings of healthcare in his province.

“This issue of accountability is a big problem and we don’t expect this from our nurses,” he said, but he stopped short of offering any interventions that the department may have to address the issue. In his allotted time to address the gathering, Nkosi asked for the Ritshidze recommendations that were presented and said this would allow the department to respond more thoroughly.

Nkosi maintained that the complexity of the problems of poor service and staff attitudes stem from the legacy of apartheid. He said that in playing catch up to provide services for a grossly underserved community, facilities built in the mid-1990s were too small and were not located where the need was greatest.

Now 27 years into democracy, he said the government is still trying to match limited resources (including human capital) with growing need and he said this was a contributing factor to why clinics are often overcrowded and waiting times are long. For the nurses and clinic staff it becomes workplaces that leave them overstretched and also often inevitably irritable and frustrated, he added.

“What the department has done — and we are not there completely but it is a start — is to move from facilities-based care to community-based services,” he said.

Nkosi said in the next financial year the target for the province is to have 500,000 patients enrolled to receive chronic medicine and some services like HIV testing to be available in their communities – not a clinic. This includes collections of multi-month scripts at external pick-up points, like supermarkets. According to the Ritshidze data currently around 52% of patients receive two months’ supply of ARVs, around 37% receive three months’ supply but still about 10% receive a one month supply in the province.  

“What I think has been most encouraging is that people are availing themselves for clinic services – that’s why we do have these big numbers of people on ARV treatment,” he said.

Ritshidze’s community-led monitoring report, sets out clear targets and recommendations for the government to move with greater urgency and political will. 

Sibongile Tshabalala, National Chairperson of Treatment Action Campaign (TAC) — one of the organisations that forms part of Ritshidze — was part of the presentation panel at the Mpumalanga community accountability meeting.

Tshabalala said the power of accountability meetings comes from being able to present firm evidence in data, photographs and community accounts as well as recommended solutions.

“The meeting closes a gap and brings the perspectives of the community and shows the evidence. We have been making noise for a long time, but without evidence they dismiss us. That’s why we will keep on monitoring and we will keep on presenting this information,” she says.  

She also noted that staff attitude, while being a national problem, showed up as the overriding issue that community members in the province wanted addressed. Tshabalala said it was a “poor excuse” to put staff attitude down to a legacy of apartheid, as Duma had set out.

“To come here 27 years later and tell us as civil society and activists, that staff attitude problems are about apartheid – we can’t accept that,” she said.

Tshabalala said to move forward more community consultations between community members and clinics staff and managers need to take place. TAC members have facilitated these community-level meetings in the past, which will now be facilitated more widely through Ritshidze. Tshabalala said these meetings are successful in promoting communication and for creating a neutral space where all sides can present their problems and importantly, for all sides to listen to each other with a hope of “starting to mend relationships”.

She added: “As much as we say bad staff behaviour and bad attitude must change because it is chasing people from facilities; we understand the working conditions nurses are faced with. They are not supported by the department, so they also have stress and frustrations.”

“Nurses have to be nurses and social workers at the same time but when there are 150 patients a day they have to see there’s no time or space to check everything.”

She said that the accountability meetings are important instruments to close the gap between recommendations becoming targets then becoming implementable interventions.

This includes the key deadline relating to staffing and its impact on waiting times. The recommendation is for Mpumalanga Department of Health to release the provincial human resource health plan by the end of June 2021 that details all the list of vacancies. By the end of the year all of these vacancies must be filled and an audit needs to be undertaken to develop a turnaround strategy by end August 2021 to prioritise staffing needs for the next financial year.

Another issue raised in the report and the meeting is the need for better filing systems. The Ritshidze report showed how patient files are not kept electronically or in an organised manner in a large number of facilities. Because of this patient files go missing, can’t be easily located — adding to waiting times — and often new files have to be opened each time a patient has an appointment. It comprises the continuity of patient care. The Ritshidze findings showed that 21.7% of monitored clinics had inadequate filing systems. Eight of the clinics had disorganised filing systems in place because of a lack of space.

The need for improved infrastructure also dominated in the meeting. In 60% of the clinics toilets were in a poor condition, and 88% of facilities did not have enough space and shelter for patients to wait comfortably, for consultation, storage and filing. Added to this is that there was a lack of cleaning staff to ensure good hygiene of facilities, the report found.

Among the other key issues raised were discrimination and lack of services for key population groups. Among the findings were that of the clinics observed none offered specific services for people who use drugs; only one offered hormone therapy for trans people; eight offered HIV testing and counselling for men who have sex with men and only seven clinics offered sex workers lubricants.

The recommendations are for better sensitisation of clinic staff to the needs of key population groups and for a minimum package of services to be introduced across all facilities.

Another low-scoring area was in TB infection control. Ritshidze’s community monitors in the province found that not a single clinic met the basic criteria to ensure that clinics are safe in not adding to the spread of TB.

Ritshidze uses a six point checklist. These are ensuring enough room and space for patients to wait without overcrowding; keeping windows open; ensuring TB information posters are prominently displayed; reducing clinic waiting times to less than an hour and 15 minutes; screening all patients for TB symptoms on arrival and separating patients who are coughing from other patients.

Ritshidze has called for an audit by the Department of Health to be completed by the end of August to ensure that clinics implement these six basic control measures.

The overall quarterly findings and report back show that the province needs to have more plans, targets and timelines in place and to match this with competence, capability and commitment to get the job done. 

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