• 3rd edition of State of Health report compares data over the last three years of community-led monitoring in Mpumalanga
• The data, together with stories from people living with HIV, key populations and other public healthcare users, will be presented at two district community meetings — in Ehlanzeni (13 June) and Gert Sibande (15 June) this week
• The meetings will be live streamed on vimeo/vimeo, Facebook and YouTube.

Mbombela, 13 June 2023 — “I went to Ermelo Clinic as I ran out of treatment. When I got there, they requested a transfer letter. I told them that I cannot get it… They said they cannot help me without the letter. I asked for at least a 1 month refill… they didn’t give me anything.”

In the last year 297 people interviewed by Ritshidze across Mpumalanga had been denied health services because they did not have a transfer letter — something that is not required in national adherence guidelines to start or restart your ARVs. Shockingly in Nkangala alone, 22% of respondents told us they had been denied services without a transfer letter — more than in any other district monitored by Ritshidze. 

Alarmingly 433 people also told us they had been denied services without an identity document. One community member explained: “They said they can’t help because I’m not a South African citizen and I had no transfer letter… I told them that I am staying far away and just got a job…. I wouldn’t have wanted to give my unborn child HIV because I needed a transfer letter… They refused to assist me without an ID book.”

Key populations we interviewed had also been refused access to health services: including 10% of gay, bisexual, and other men who have sex with men, 26% of people who use drugs, 11% of sex workers, and 13% of trans* people. A violation of the Constitutional rights to health, equality, and human dignity.

As one community member told us: “They never treat me very well at the clinic, I went there in January and hoped they would help me. They did not… they chased me away, told me that I am dirty and that I would steal from other patients. I told them I needed help… but they just chased me away” — and another person recounted their experience going to the clinic after being shot: “when I got there I got chased out by the nurses saying that I’m a “nyaope boy”, that they should’ve shot me dead… they said I don’t deserve to live”.

People being refused services are among nine key issues outlined in the third edition of a new Ritshidze State of Health report in Mpumalanga. The report will be launched at two district community meetings this week — in Kabokweni today (Ehlanzeni), and Ermelo on Thursday (Gert Sibande). 

In positive findings, waiting times have reduced by nearly an hour in the last year in facilities monitored, down to an average of 3:12 hours waiting after the facility opens. However, some people still spend many hours at each visit to the facility — which is a major source of dissatisfaction. 59% of people still reported long waiting times — with 37% blaming staff shortages and 43% blaming disorganised filing systems. Further only 56% of facilities have a generator that is working and has fuel — this means during loadshedding that 49% of sites face challenges in finding files in dark filing rooms, adding to waiting times. 

“The main challenge for me is the filing area,” one community member explained. “You queue outside for 2 to 3 hours… and you are still going to wait in another line where we produce the small cards to retrieve files. You can spend another hour in that line… sometimes they will tell you that they can’t find your file and you need to wait while they look for it.” 

Another said: “Three months ago I went to the clinic… my file was missing. They had me waiting for about 2 hours. After 2 hours they told me to go to the reception and ask for my file. When I got there, the admin clerk asked me in front of everyone if it was my first time collecting treatment? She was shouting as she asked me in front of everyone. I was hurt… and then I left without my treatment.” 

One strategy to ease these delays is for people who are just collecting medicines to get a longer supply. This simply means fewer trips back to the clinic. Positively, this year 64% of people living with HIV we spoke to had gotten a 3-6 month ART refill, up from 49% last year. Mpumalanga scored best on this indicator out of all provinces monitored by Ritshidze. However, of concern are reports from the national health department that the number of active people receiving a three month supply has actually decreased from 175,404 to 109,303 in the province.

Another strategy to reduce congestion is to go straight to a pick-up point to collect ARVs. Yet 65% of people using facility pick-up points told us that they must still collect files, take vitals, and see a clinician before getting their parcel — adding unnecessary delays. Of those still using the facility, 48% said they had never even been offered the option to collect from a pick-up point — and 52% wish they could collect their ARVs closer to home. 

Staff attitudes remain a challenge. Only 62% of people thought that clinic staff were always friendly and professional — and only 44% of people living with HIV said staff are welcoming if they missed an appointment. Unwelcoming treatment is a major reason why people disengage from care — as one community member put it: “The nurses shouted at me and I was not treated well when collecting my treatment. They would ask me what I came back for again. That’s when I stopped going to the clinic to collect my treatment”.

Another explained: “I did not miss my appointments because I enjoyed doing so, sometimes I missed them due to not having transport money as I am unemployed. When I go to the clinic, she will shout at me, asking why did I not come to the clinic? Why am I skipping the dates? If I want to die why don’t I do that? Why do I keep bothering them? I ended up not going back. I am taking ARVs and I did not take them for almost 2 months. I never lodged a complaint as I was scared of the nurse.” 

Further, only 40% of gay, bisexual, and other men who have sex with men said staff are always friendly, only 24% of people who use drugs, only 48% of sex workers, and only 47% of trans* people — and the majority of key populations interviewed did not feel safe or comfortable at the facility.

One sex worker told us: “Whenever I go to the clinic, they would always ask “why do I do my job, why do I sell my body, isn’t there any other job I can do besides selling my body?” I have even decided not to go to the clinic anymore because of the treatment that I get there. Anytime I went to the clinic, I always came back heartbroken because of the way I am treated there.”

For key populations who do continue to suffer the hostility of using the public healthcare system, key services remain out of reach. Lubricants could be found at only 40% of sites monitored. While PrEP is reported as available in all sites, far fewer are actually offering it to key populations. Only 9% of people who use drugs were offered information about where they could get new needles and only 22% were given information on where to get methadone. While 19% of trans* people said facilities had no knowledge of hormone therapy at all.

“We do commend the Mpumalanga health department for the clear progress on waiting times over the last year and for getting more people on 3 month supply of ARVs. However, while there has been some progress, we also continue to see and hear about challenges that make it hard for someone to access HIV and TB prevention and treatment,” said Sibongile Tshabalala, from the Treatment Action Campaign (TAC). 

“In particular, we are extremely concerned with the reports of people being turned away from clinics because of not having a transfer letter, or being a migrant, someone who uses drugs, a sex worker, or from the LGBTQIA+ community. This is a violation of people’s rights. The province must urgently ensure that no-one is refused services — and continue to be open to hearing the problems and taking rapid action to fix our clinics more broadly, so that everyone can access the HIV, TB and other health services they need.” 

For more information or to arrange interviews contact:

Ngqabutho Mpofu | +27 72 225 9675 | ngqabutho.mpofu@tac.org.za 

Lotti Rutter | +27 82 065 5842 | lotti@healthgap.org

Note to editors:

This is the third edition of the Mpumalanga State of Health report; the first was published in May 2021 and the second in June 2022. 

This week, Ritshidze is providing a platform for community members to raise their concerns directly to the Ehlanzeni and Gert Sibande health departments, the Mpumalanga health department and national health departments, and PEPFAR partners working in the province, Broadreach and Right to Care. 

To follow proceedings virtually please join at: 

Ehlanzeni: Tuesday 13 June: Vimeo | YouTube

Gert Sibande: Thursday 15 June: Vimeo | YouTube

The full Mpumalanga State of Health report is available here

The Ehlanzeni presentation is available here

The Gert Sibande presentation is available here

A summary report is available here

A summary of recommendations is available here

A recording will be available after the event on the Ritshidze website, Facebook, and YouTube channels.

About the report: 

The report has been developed using data from Ritshidze — a community-led monitoring system developed by organisations representing people living with HIV, including the Treatment Action Campaign (TAC), the National Association of People Living with HIV (NAPWA), Positive Action Campaign, Positive Women’s Network (PWN), and the South African Network of Religious Leaders Living with and affected by HIV/AIDS (SANERELA+). 

Ritshidze monitoring takes place on a quarterly basis at more than 400 clinics and community healthcare centres across 29 districts in 8 provinces in South Africa — including 43 facilities across Mpumalanga: 21 in Ehlanzeni, 18 in Gert Sibande, and 4 in Nkangala. Additional quantitative and qualitative data is collected within the community specific to the quality and friendliness of health services provided for people who use drugs, sex workers, and the LGBTQIA+ community. 

Ritshidze collects data through observations, as well as through interviews with healthcare users and healthcare providers. All monitoring tools are available here: https://ritshidze.org.za/category/tools/ 

Data in this report were collected between April and May 2023 (Q3 2023).

• Interviews took place with 43 Facility Managers
• Observations took place at 43 facilities 
• Interviews took place with 2,320 public healthcare users in Mpumalanga
• 51% (1,193) identified as people living with HIV
• 24% (556) identified as young people under 25 years of age

Additional quantitative data related to key populations was collected between August and October 2021. Data collection took place across two districts: Ehlanzeni and Gert Sibande (Table 2). A total of 1,010 surveys were taken, combining 216 gay, bisexual, and other men who have sex with men (GBMSM), 361 people who use drugs, 343 sex workers, and 90 trans* people. 

Follow Ritshidze on twitter, facebook and instagram for regular updates or go to www.ritshidze.org.za for more information.