- 3rd edition of State of Health report compares data over the last two years of community-led monitoring in Gauteng
- The data, together with stories from people living with HIV, key populations and other public healthcare users, was presented at three district community meetings — in Ekurhuleni, City of Johannesburg & Johannesburg Metro, and Tshwane this week (district specific data presentations available at the links)
Johannesburg, 19 January 2023 — “Sometimes you just want to ask, ‘why did you become a nurse; why did you become a clerk; why did you come to work?’”
While an improvement, dismissive, rude, and uncaring staff are still commonplace at clinics in Gauteng. Still only 65% of people thought that clinic staff were always friendly and professional — and for people living with HIV who had missed appointments, 25% said staff shouted at them upon return and 21% said that staff sent them to the back of the queue. This treatment only puts people off ever going back.
“One young woman explained to me that nurses treat patients rudely — and threaten patients too. They send people to the back of queues when they have missed appointment dates and they also threaten patients who ask questions or complain. She said then nurses will say “you will be attended to last”,” Ritshidze District Organiser Lindi Mahlangu said.
Many key populations blamed hostile staff for why they had stopped going to the clinic altogether (including 33% of gay and bisexual men, 31% of people who use drugs, 25% of sex workers, and 38% of trans* people) — as well as a general lack of privacy and the very real fear that staff would expose their HIV status or the fact they take drugs, do sex work, or are queer or trans*.
Unfriendly services are among nine key issues outlined in the third edition of a new Ritshidze State of Health report in the province. Two years down the line from the launch of the first State of Health report, while some improvement has been made, it’s evident that there are still too many shortcomings in the public health system.
Only 25% of facilities this year say there are enough staff at the facility to meet demand, a decline from 30% last year. While 44% of facilities blamed too few open positions on the shortages, almost half (48%) blamed the ever rising number of unfilled vacancies. In this reporting period, there were 561 open vacancies in the province, a sharp increase from 278 at Ritshidze monitored sites in last year’s report.
Gaps in staffing too often lead to delays. 54% of public healthcare users interviewed still think waiting times are long — and 41% pointed to staff shortages as a major reason for this. While overall waiting times have reduced by 30 minutes over the last year, from 4:24 hours down to 3:54 hours, too many public healthcare users still spend hours at each visit to the facility. An ongoing source of dissatisfaction and anxiety.
As one community member told us: “We had been sitting there long…and they just sent us home because they said they had to go to a meeting” and another said “When we were about to get the tablets, they said some of our files were lost. We had to wait yet again.”
In order to beat the queues and minimise time spent at the facility, people are pushed to arrive early with the average earliest arrival time at 5:42am across the province, and as early as 3.45am at some facilities. It is not safe to be walking to the clinic, or waiting around outside locked clinic gates in the early hours and 31% of people reported feeling unsafe or very unsafe while waiting for the facility to be open.
As one community member put it: “The clinic is supposed to open at 8am, but they will only start to work maybe at 9am, they will take a few patients and then they will go for tea. Sometimes when you ask them what’s going on they’ll just say ‘we got your card, you must sit down and wait’”.
One strategy to reduce waiting times and ease congestion is for people who are just collecting medicines to go straight to a pick-up point instead, and to get a longer supply of medication. This simply means less trips back to the clinic. Positively, this year 43% of people living with HIV we spoke to had gotten a 3-6 month ART refill, up from 38% last year. However, Gauteng still needs to do more to catch up with better performing provinces like the North West where 74% of people living with HIV interviewed reported a 3-6 month refill.
Lack of confidentiality remains a challenge. “You will come there, and you can hear them shouting ‘people for ARVs this side’ — so everyone knows what someone is there for,” one community member said of the disrespect of patient confidentiality. She says staff are also rude, shout at people and challenge people who try to tell them about their conditions or what they’re feeling — all of this taking place without any privacy.
On top of this, in the last year 301 people told us they had been denied services because they did not have a transfer letter — something that is not required to start or restart your ARVs, and 524 people had been denied services without an identity document. There is still a way to go to ensure all public healthcare users — including people living with HIV, people who use drugs, sex workers, LGBTQIA+ communities, and migrants — are treated with dignity, respect, and compassion at all times.
Communication is also lacking at facilities. Ensuring people living with HIV understand the importance of starting and remaining on treatment is another way to support long-term adherence — but this means that healthcare providers must take the time to explain people’s results and what that means, something that only 81% of people said happened. This translates to poor understanding. While an improvement, this year still only 85% of people understood that an undetectable viral load is good for their own health. Even fewer, just 68%, understood that an undetectable viral load means they cannot transmit HIV to another person, having worsened from 72% last year.
“You just come there and you collect your medicine; you can’t ask anything because they are already calling the next person so you just take your medicine and go,” one young woman explained. She says that even when she has written a complaint in the clinic suggestion box, nothing has ever been followed up. Most worrying for her, she said that she has no idea what her viral load is, and no one communicates to her about blood test results when she has tests done. She says she’s just told that everything is in her patient file and it’s all fine.
“Shortcomings in the health system in Gauteng all contribute to slow progress towards getting everyone on HIV treatment, or giving people access to HIV prevention options. Since we started documenting challenges there has been limited implementation of Ritshidze recommendations in the province and importantly the lessons that should be learnt if the public healthcare system is to improve,” said Anele Yawa from the Treatment Action Campaign (TAC).
“The Department of Health as well as PEPFAR District Support Partners must address the challenges identified, and use the solutions recommended, if we are to get more people accessing the HIV and TB prevention and treatment they need.”
For more information or to arrange interviews contact:
Ngqabutho Mpofu | +27 72 225 9675 | firstname.lastname@example.org
Lotti Rutter | +27 82 065 5842 | email@example.com
Note to editors:
Like the earlier editions, the third edition of the Gauteng State of Health report outlines key challenges people living with HIV, key populations and other public healthcare users face in the province. The report focuses on the following critical themes: staffing; waiting times; ART collection; ART continuity; treatment and viral load literacy; accessibility of health services for key populations; the implementation of index testing to find people living with HIV; infrastructure and clinic conditions; and TB infection control.
The full Gauteng State of Health report is available here
The Ekurhuleni presentation is available here
The City of Johannesburg & Johannesburg Metro presentation is available here
The City of Tshwane presentation is available here
A summary report is available here
A summary of recommendations is available here
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 123 facilities across Gauteng: 46 in the City of Johannesburg & Johannesburg Metro Municipality, 25 in the City of Tshwane, 40 in Ekurhuleni, 9 in Sedibeng, and 1 in the West Rand. 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 October 2022 and November 2022 (Q1 2023).
- Interviews took place with 122 Facility Managers
- Observations took place at 123 facilities
- Interviews took place with 6,588 public healthcare users
- 54% (3,518) identified as people living with HIV
- 62% (4,073) identified as women
- 12% (780) 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 three districts: City of Johannesburg, Ekurhuleni, and Sedibeng (Table 2). A total of 823 surveys were taken, combining 131 gay, bisexual, and other men who have sex with men (GBMSM), 372 people who use drugs, 251 sex workers, and 69 trans* people.