The second Ritshidze North West State of Health Report shows that a provincial department — just emerging from being under administration since 2018 — remains a long way off from meeting public healthcare users’ needs adequately.
A call for urgent action and accountability by the Department of Health came at the launch of the second Ritshidze North West State of Health report on 21 July in Mahikeng.
In his opening remarks, Anele Yawa (General Secretary of the Treatment Action Campaign) who chaired the Ritshidze report launch proceedings welcomed the fact that two meetings had taken place between the Ritshidze monitoring team and provincial health officials ahead of the report launch. The parties committed to follow-up meetings and to work together on turning the Ritshidze recommendations into targets, he said.
However, he also later pointed out that “A huge amount of the health budget does not go to services but goes to medico-legal claims over negligence.”
“I wish that the Department of Health could pay attention before these become matters dealt with in court by SECTION27, Lawyers for Human Rights and the South African Human Rights Council and then the department will have to spend money that it doesn’t have.”
This second edition of the North West State of Health Report has shown that massive failings in healthcare still abound that means the risk of wasting health budgets on settling court cases remain a constant drain and a continued deficiency in healthcare management in the province.
The 2022 report showed slow progress in the province in extending ARV refills for people living with HIV. The province continues to rank the worst in the country in terms of refill lengths. Only 6% of people living with HIV in the province reported three-month ART supply. In neighbouring Mpumalanga, by comparison, this number is 41%.
3 or 6 month supply of ARVs for stable people living with HIV, along with external pick-up points, are two clear strategies shown to ensure people are able to access medicines easily and are encouraged to stay on treatment.
But in the province, in addition to the low level of people getting longer supplies, stockouts are persistent, there are poor staff attitudes that include bullying and neglect; deteriorating infrastructure; and long waiting times (still over four hours on average). These are known factors that impact negatively on public healthcare users, including those on HIV treatment, in terms of seeking medical help timeously; staying on treatment; and feeling supported in returning to treatment when they have missed an appointment or disengaged from care.
Even though the reports of stockouts are down from 895 in last year’s report to 398 across 56 facilities this year, it still makes the North West the worst performing province on this indicator. Community members’ recorded stories and stories told during the report launch had a key theme of being bullied by nurses, being judged and not being able to get professional, dignified services from their clinics.
The monitoring this past year showed that for key populations (KPs), who are at higher HIV risk, face the most harassment and in some cases people complain of outright hostility. The disproportionate impact of HIV on KPs compared to the general population means their specific needs call for critical attention.
Only 33% of respondents reported that facility staff are always friendly and professional towards gay, bisexual, and other men who have sex with men; 35% towards people who use drugs; 33% towards sex workers; and 40% towards trans* people.
Community members confirmed the report’s findings that “these factors drive key populations away from accessing critical HIV, TB, STI and other health services”.
Some of the discriminatory and offensive questions people said they are subjected to include being questioned about their sex lives, asked probing questions about why they were taking ARVs “at their age” or having their privacy and confidentiality dismissed. Some KPs said they decided to stop going to their clinics all together because their clinic experiences ended up being tense and stressful.
Yawa said: “The right to health is a fundamental human right. We need to agree that anyone who is denied access to health whether it is through stigma, discrimination, being shouted at or non-availability of treatment — that person is being violated.”
Yawa added that nurses needed to keep their judgements, religions and culture out of clinics. This even as he acknowledged that staff shortages and poor management of staff continue to be massive contributing factors to poor staff attitudes, abuse of power by nurses and ultimately, of negligence.
Ritshidze Community Monitors also found a disturbing sentiment that in spite of more staff vacancies being filled this year compared to last year, public healthcare users expressed that they are in fact experiencing worse service.
The report found an increase from 61% (in Q3 2021) up to 75% (in Q3 2022) of respondents reporting that there are never or only sometimes enough staff at the facility. In this reporting period only 11% of public healthcare users interviewed reported that there are actually always enough staff at the facility. Meanwhile the province’s records show that this year they have only 39 vacancies at three facilities that need to be filled, compared to 61 vacancies at three facilities reported last year.
Ritshidze’s recommendations in this regard are a target of filling 80% of vacancies in the province (including the 39 vacancies reported at Ritshidze-monitored sites) by January 2023 and the remaining 20% by the end of the financial year. Also that the North West Department of Health should produce annual reports on the numbers of healthcare workers (divided into sub-groups such as CHWs, professional nurses, and doctors) employed in each district and the numbers of people and size of areas covered by these healthcare workers. These reports should also include year-on-year comparisons (from at least 2020) of the number of filled posts in all districts and the cost of these posts to the government.
The full set of recommendations set out in this second year’s State of Health Report now have the benefit of comparative data and with this clearer insights and analysis. It means interventions can be more appropriately targeted and importantly that the community-led monitoring has given rise to compelling evidence for the Department of Health to act.