By Ndivhuwo Rambau, Sibongile Tshabalala and Brian Honermann. This op ed was published in Spotlight and the Daily Maverick.
Ritshidze is a system of community-led monitoring that has been developed by people living with HIV and activists to hold the South African government and aid agencies accountable and together improve HIV and TB service delivery.
Initiated in 2019, Ritshidze activists are implementing a model of detailed monitoring at over 400 public health facilities across eight provinces and 29 districts in the country on a quarterly basis. These 400 primary health facilities are responsible for delivering HIV services to over half of all people currently on HIV treatment in South Africa. Through observations as well as interviews with healthcare users, facility managers, and pharmacists every quarter, Ritshidze is monitoring over 140 indicators of the quality of the healthcare system.
Unlike most healthcare system assessments funded by government and aid agencies that focus on the number of services being provided and tracking — in broad terms — patient outcomes, Ritshidze’s monitoring systems have been developed specifically to capture the persistent and intractable problems of the quality of healthcare service delivery in the country. These data can then hold duty bearers responsible for implementing fixes and corrections to improve service quality. Indicators include supplies of medicines and stockouts, compliance with TB infection control standards, human rights and privacy of patients, long waiting times, inadequate human resources, staff attitudes, and decaying and insufficient clinic infrastructure.
SA Lagging on Key Indicators
For example, last April during the first wave of COVID-19 in South Africa, the National Department of Health (NDoH) issued a strategy document to reduce the risk of COVID-19 to people with HIV and TB. There were five priority interventions which included “[a]ccelerat[ing] decanting to external pick up points (PUPs)” and “[i]mplement[ing] multi-month dispensing for all chronic patients”. Ritshidze data show that neither of these priorities have substantially improved since the NDoH released this document. Ritshidze data show that between October 2020 and June 2021 — of the nearly 18,000 patients Ritshidze has interviewed at these 400 facilities, 61% are still collecting their ARVs through standard facility dispensing in these clinics and less than 1% of people living with HIV have been provided with 6-month dispensing of ARVs. The majority of people living with HIV are still reporting having to collect ARVs every 2 months (61%). This week at the 11th IAS Conference on HIV Science PEPFAR presented data highlighting how South Africa is substantially lagging behind other countries in this regard. Across the 50 other countries where PEPFAR supports HIV treatment programmes, by June of 2020, 16% of people living with HIV were already receiving 6-month dispensing of ARVs and 53% were receiving between 3 and 5 months. Over a year after other countries have reached these levels of multi-month dispensing, only 23% of people in South Africa get 3-months of ARVs or more. In their 2021 guidelines, the World Health Organization (WHO) strongly recommends that people established on ART be offered refills of ART lasting 3-6 months, preferably 6 months.
This is unacceptable and made even worse in the time of COVID-19 where it is established that people living with HIV are at increased risk of hospitalisation and death from COVID-19. Failing to implement these policies exacerbates the vulnerability of people living with HIV to COVID-19 by exposing them to clinic conditions more often than necessary.
Unique to Ritshidze is the ability to drill into these issues on where — which provinces, districts, and clinics — require intervention on these issues. While no province is doing well, there are significant geographical differences. Limpopo, Eastern Cape, and Free State are all — on average — dispensing less than two months of ARVs to people living with HIV, with many individuals still collecting monthly refills. Mpumalanga and Gauteng are — by contrast — performing better with people living with HIV getting more than 2 months on average.
Only half of the districts monitored by Ritshidze show more people living with HIV receiving 3-month refill lengths than 1-month, with districts like Nelson Mandela Bay (EC), Ehlanzeni (MP), and King Cetshwayo (KZN) leading the way, while districts like Capricorn (LP), Mopani (LP), and Lejweleputswa (FS) are dispensing far more 1-month supplies than 3-month. Facility level data show which specific facilities are failing to implement and dispense medicines appropriately as well, with 18 facilities dispensing more 1-month supplies of ARVs than either 2 or 3-month supplies combined. Data such as these tell us not only what is failing, but where efforts must be focused to resolve these problems.
New Public Dashboard
While Ritshidze harnesses this data for advocacy and feedback to facilities, it is critical that the community of South Africa, health journalists, policy-makers, and all duty-bearers have access to them to also assess the health system. This is why Ritshidze is making our data publicly accessible online at http://data.ritshidze.org.za.
The dashboard — developed by amfAR — provides an easy-to-use interface for all stakeholders to access, download, and analyse our data.
One note, while Ritshidze does monitor several facilities in the Western Cape, the Western Cape Department of Health has not yet given full permission to monitor and release any data on the Western Cape publicly. We are still in discussions with the Western Cape Department of Health and hope that this issue will be resolved soon.
Rambau is a Ritshidze Project Officer, Tshabalala is National Chairperson of the Treatment Action Campaign (TAC), and Honermann is the Deputy Director of Public Policy at amfAR. Follow Ritshidze on twitter, facebook and instagram for regular updates or go to www.ritshidze.org.za for more information.