Ritshidze survey of over 22,000 patients in over 400 clinics across South Africa reveals progress and persistent challenges for public health users

  • National State of Health report looks at data from community-led monitoring across 400 sites in South Africa, and challenges identified by TAC’s 280 branches across the country
  • The data, together with stories from people living with HIV, members of key populations, and other public healthcare users, will be presented at a community meeting today
  • The meetings will be live streamed on vimeo, Ritshidze’s facebook, TAC’s facebook, and YouTube

Mamelodi, 7 December 2023“I leave around 5am to go to the clinic. When we get to the clinic we will not be helped on time and will leave around 2pm to 3pm.They go around circles, having tea and only start working around 11am. When you write your complaints, they take them out and tear them apart.” 

Now in the 4th year of implementation, Ritshidze data continue to show that public health facilities are not currently providing services at the standards and expectations of national guidelines, or public healthcare users themselves. Overall, waiting times at facilities have improved more than 25% since 2022, averaging 3:07 hours down from 4:22 hours. However, improvement is still highly variable. KwaZulu-Natal, Limpopo, and Mpumalanga all have average waiting times less than 3 hours, while Western Cape and Free State have average waiting times over 4 hours. 32 of the 419 facilities assessed (8%) have waiting times over 5 hours and 8 have waiting times over 6 hours.

Half of public healthcare users we spoke to felt that waiting times at their facilities were too long. And the length of time undermines programming. “I wake up at 3am… but it doesn’t make a difference because I come back home at 4pm. It doesn’t matter how early you get there — you’ll still leave late in the afternoon”.

Most of the challenges with waiting times are attributable to understaffing — 75% of facility managers report not having sufficient staff with more than 1,300 staff vacancies reported across these 419 facilities — and inadequate filing systems — 40% of public healthcare users complain that retrieving files is a cause of long waiting times.

“I have not collected my treatment because each time I go they cannot find my file. I stopped taking my ARVs. I feel very bad about this because I have lost weight and I am unable to eat… It hurts to not get my treatment.”

Loadshedding is also undermining public clinics. Only 55% of the facilities reported having working generators with sufficient fuel. 29% reported no generator, while 14% reported either having no fuel or a non-working generator. According to facility managers, loadshedding in these sites then leads to problems with pharmacies being unable to dispense medications (62 sites, 24% of those without working generators) and pick-up points such as ARV ATMs or Peleboxes stopping working (16 and 18 respectively). 85 (33%) reported concerns with medication spoiling. 155 (61%) reported that the filing room not having lighting means they cannot continue finding files.

Generator problems are again highly unevenly distributed. In the Free State, for instance, only 1 of the 24 sites assessed has a working generator, while in Gauteng 80 of the 121 sites (66%) have working generators.

ARV refill collections continue to be highly inefficient and burdensome for people living with HIV. While a slight improvement has taken place between last year and this year, that has only been seen in some people moving from two month to three month refills. Overall, only 52% of people are getting 3 month refills, and 41% are less than 3 months. Comparatively, other countries throughout Africa report having more than 80% of people living with HIV getting at least 3-6 months worth of ARVs per pick-up.

I am on ARVs. I am not satisfied with the 2 month refill that I get. I would like to get 3 or 4 months refill. That way, I will only go to the clinic 3 or 4 times a year.” 

Importantly, solutions to many of these problems already exist. Satisfaction with external pick-up points is over 91% and 78% for in facility pick-up points.

Staff Continue to Violate Patient’s Rights

Between January and November 2023, 1,366 people have told us that they have been refused services without a transfer letter from another facility. 2,083 told us they were refused services for not having an ID. 252 told us they were refused services for not being South African. In our interviews of members of key populations, 164 gay, bisexual, and other men who have sex with men (GBMSM) had been refused services because they were GBMSM, 1,537 people who use drugs were refused services, 231 sex workers, and 106 trans people, because of these characteristics.

Critically, while these numbers represent an overall small minority of the people we surveyed during this time (86,748 patient surveys), we note that our interviews primarily only take place at facilities, so people who have already given up on accessing care because of such denials of services won’t show up in our data. Additionally, for things like transfer letters and being refused for not being South African, only a very small overall percentage of people actually would need a transfer letter in a given year because most people don’t transfer facilities regularly. Similarly, non-South African citizens are a small overall percentage of the people using public health services such that these numbers of denials must be interpreted as representing larger overall percentages of those affected populations.

“I have not taken my ARVs in a few months because the facility requires a transfer letter. They tried contacting my previous facility but they couldn’t speak to anyone there. I suggested that they test and reinitiate me as a new patient, but they said that would be difficult. I gave up and stopped trying.

For key populations, only 33% of GBMSM, 17% of people who use drugs, 26% of sex workers, and 35% of trans people report that staff are always friendly toward them. Comparatively, 69% of public healthcare users say “yes” when asked whether staff are friendly and professional.

“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 go to the clinic, I always come back heartbroken because of the way I am treated there.”

Very few members of key populations report feeling very safe accessing services in public clinics (GBMSM: 7%, people who use drugs: 4%, sex workers: 5%, trans people: 7%) and a very high percentage report that their privacy is not respected in the facility (GBMSM: 57%, people who use drugs: 74%, sex workers: 65%, trans people: 61%). By contrast, only 3% of people interviewed in our general patient survey reported that facilities don’t maintain confidentiality for people living with HIV.

“The nurse gave me my pills in front of everyone and said “we are really tired of you, who knows maybe you are smoking these pills. Why can’t you just die because you’ve already killed yourself with drugs. You don’t even bathe and don’t like yourself”. I was offended as everyone was staring at me.”

South Africa is far off track in meeting our needs in responding to the HIV epidemic and the slow overall progress that we’ve seen, while beneficial, is insufficient. This year’s report again calls for urgent action and reform with specific recommendations for improving service delivery for people using the public healthcare system.

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:

Today TAC and Ritshidze are providing a platform for community members to raise their concerns directly to the national health department, provincial MEC’s for Health, PEPFAR, USAID, CDC, the Global Fund, and the Office for Health Standards Compliance. Duty bearers are afforded the right to respond. 

To follow proceedings virtually please join at: 

Vimeo | YouTube | facebook  | facebook

The full National State of Health presentation is available here

About the report: 

The report has been developed using data from Ritshidze. 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. 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 and November 2023 (Q1 2024).

  • Interviews took place with 418 Facility Managers
  • Observations took place at 419 facilities
  • Interviews took place with 22,543 public healthcare users — 51% identified as people living with HIV, and 15% identified as young people under 25 years of age

Additional data were collected between July and September 2023 among communities of key populations. Interviews took place with: 2,616 gay, bisexual, and other men who have sex with men, 6,106 people who use drugs, 3,721 sex workers, and 1,425 trans people. We will present some of our preliminary analysis today — and our full report will be launched early next year.

You can follow TAC on twitter, facebook, and instagram or go www.tac.org.za for more information. 

You can follow Ritshidze on twitter, facebook and instagram or go to www.ritshidze.org.za for more information.


“Ritshidze” — meaning “Saving Our Lives” in TshiVenda — has been developed by people living with HIV and activists to hold the South African government and aid agencies accountable to improve overall HIV and TB service delivery.

Partner organisations include 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+)—in alliance with Health Global Access Project (Health GAP), the Foundation for AIDS Research (amfAR), and Georgetown University’s O’Neill Institute for National and Global Health Law.

CLICK HERE to read more and see where we work.