Quality healthcare is not a favour from government, and politicians who make excuses and hide from facing the reality of mounting complaints about poor service delivery are part of the problem.
Sibongile Tshabalala, the National Chairperson of the Treatment Action Campaign (TAC), which is one of the Ritshidze partners, sent a clear message to under-performing officials in the Limpopo province, who refused to come to account at the launch of the Ritshidze Limpopo State of Health report in Polokwane.
Chairing the community accountability meeting that took place on 26 August, Tshabalala said: “We are not happy about this attitude that we are getting from district and provincial health when it is time for them to come to respond to issues the community is raising.”
“It is not okay for them to say to us how we should raise our voices or when we should publish our reports. They could have dealt with problems they said they are having before this event — not on the day — if they had bothered to respond to our email invitation on time. We contribute to our healthcare and this is our right,” she said.
She added that the Ritshidze’s community-led monitoring should in fact be viewed by government as a partnership and a potential tool to better identify ways to improve services. Creating benchmarks for clinics and hearing directly from community members is a revealing glimpse at realities on the ground — “if you want to do your job better,” said Tshabalala. The data that’s been collected and analysed in the report shows up gaps in service in the province but also points to where solutions or interventions can be made.
Officials representing National Department of Health structures logged on virtually to the launch, but the no-show from officials at provincial and district levels is a damning reflection of how health services have deteriorated. This includes how low-performing officials, nurses and other staff continue to be employed in the department without sanction. We need clear steps on how the Department intends to improve the skills and training of staff; and what consequences there are for DoH employees who continue to deliver sub-standard services.
The State of Health Report for the province focused on 17 clinics and community healthcare centres and data was collected through interviews with patients and facility staff, as well as observations in the period between April and June 2021.
The model of community-led monitoring gives communities a bigger role in monitoring the quality of service in facilities they rely on. The data collected, along with analysis and stories of community members, round up a thorough Ritshidze strategy to document the failures in service that are impacting on HIV and TB service delivery across South Africa.
One of the key issues raised in the report for the province relates to long waiting times and critical understaffing. On average, people interviewed reported that they could wait around six hours to be attended to during a clinic visit. Those who spoke at the Polokwane meeting said they are often up before dawn to be in a clinic queue on their appointment dates. It comes with the risk of being mugged or attacked but they felt they had few other options and believed that being in the front of the queue was the best chance of getting helped.
Added to this problem, was the fact that there are currently 30 vacancies across the 17 clinics monitored. Of the Facility Managers interviewed, 94% confirmed that insufficient human resources count as one of their biggest challenges.
The report also outlined the patchy appointment systems at clinics and poor filing and patient record keeping. All of these elements contribute to long waiting times.
For one woman, who spoke at the Polokwane launch, she recalled a recent appointment when she had to wait for an entire morning only to get to the front of the queue to receive her patient file.“When I got to the cubicle they told me I had to come back another day because the doctor wasn’t there,” she said.
She returned on her new appointment date and again waited for hours before seeing a doctor who told her that she would have to return again because she needed to be seen to “by another doctor”.
Some of the recommendations Ritshidze has made, include opening clinics premises by 5am so people have a safe place to wait; also to extend operating hours between 5am to 7pm. Ramping up external pick-up for stable patients must also be done to reduce patient numbers in facilities.
It is well established that putting in place the correct support structures and making it easier for people to access their medicines are the best strategies to ensure people stay on their treatment regimes.
The report also outlined that the province lags behind in multi-month ART dispensing. Currently the report showed that only 2.1% of PLHIV receive 3-months’ supply and only 51.5% receive 2-months’ supply. 46.4% of PLHIV receive 1-month or less supply, shocking considering the national standard is at least 2 months. This problem is compounded by the fact that 50% of patients reported stockouts and that they frequently left the clinics empty-handed. It was also noted that 24% of facilities monitored had a shortage of HIV and PrEP in the last reporting period; 82% of facilities monitored had a shortage of contraceptives and there was a 76% shortage of vaccines.
Ritshidze recommendations are that there should be better communication and monitoring to ensure alerts before stocks run low and for better training of staff to ensure improvement in stock management and procurement.
Another key concern highlighted in this quarterly report is the level of treatment literacy. When people understand their conditions and treatments there is better linkage to care and higher retention rates of people staying on treatment.
Ritshidze monitoring revealed major gaps in knowledge about what an undetectable viral load test means. Encouragingly, 96% of PLHIV had a viral load test done in the last year, and 91.8% of participants living with HIV reported knowing their viral load. However, in some districts, people didn’t understand viral loads and how this impacts on their own health and transmission.
PLHIV in Rethabile CHC, Buitestraat Clinic, Perskebult Clinic, Nobody Clinic, and Seshego IV Clinic, all located in Capricorn, were the least informed about the meaning of viral loads. Only 79% of those interviewed said that a healthcare provider had explained the results of the viral load test results to them. In terms of the transition to dolutegravir (DTG), only 62% of PLHIV were on a DTG-based regimen. However, more positively, 94% of those PLHIV were given an explanation of the potential side effects of DTG.
Another key issue that emerged in Limpopo is the discriminatory and insensitive attitude some nurses and clinic staff have toward key populations, including sex workers and members of the LGBTQI community.
For one person who spoke at the Polokwane report launch, he was humiliated by questions about his sex life as a gay man. When he asked a nurse for lubricants he was told “why do you need lubricants if you are not a woman?” he said.
He told the nurse “as a gay I am playing a women’s role, but I was very angry and even then she didn’t give me the lubricants”.
Another woman told of how in 2019 she arrived with her child for emergency care at a clinic. “They didn’t want to help me and said that I would be the last person they would see to. They went to lunch without helping my child —that hurt me a lot. They were saying things to me like I make a lot of money as a sex worker I should be at a private doctor — they were judging me,” she said.
Ritshidze’s community-led monitoring will continue in the next quarter to find these stories from communities to let their voices be heard. The recommendations that have clear timeframes for government to act will also be monitored because the health department must come to the party and take the right steps to do better.