KwaZulu-Natal clinics are outperforming facilities monitored in other provinces on various indicators and health services in the province have improved year-on-year, but some marginalised groups continue to have a hard time accessing healthcare services. This is according to the latest provincial report from community-led monitoring project Ritshidze.
Like last year's edition, the second edition of Ritshidze's KwaZulu-Natal State of Health report outlines key challenges people living with HIV, key populations, and other public healthcare users face in the province. Key populations refer to those identifying as transgender, gay, bisexual, and men who have sex with men, sex workers, and people who use drugs.
Ritshidze monitored 131 facilities across the province, most of which were in eThekwini district. Interviews took place with facility managers and 7 973 public healthcare users - of which 52% (4 173) identified as people living with HIV, 68% (5 491) identified as women, and 22% (1 713) identified as young people under 25 years of age.
Some progress
According to the report, over the last year, the province has reduced average waiting times at facilities (after facilities open) from three hours and 20 minutes to two hours and 39 minutes - a reduction of 41 minutes. The report also notes that 30 facilities had average waiting times of under 2 hours, making KZN the province with the shortest waiting times at primary healthcare facilities monitored by Ritshidze. Ritshidze currently monitors facilities in all provinces except for the Western Cape and Northern Cape.
The report also found that more people are receiving multi-month supplies of ARVs, which means people can visit health facilities less often.
Another area where the province showed encouraging progress is healthcare users receiving "friendly and welcoming services" - an important factor in supporting long-term treatment adherence and retention. "Positively, 82% of people thought that the staff were always friendly and professional, up from 75% last year and 95% of people living with HIV feel that facilities keep their HIV status private and confidential", the report states.
Speaking on the issue of staff attitudes, provincial health department spokesperson Ntokozo Maphisa says the department has an ongoing training programme focusing on customer care, professional ethics, Batho Pele Principles, and patient rights in different sub-districts.
According to Maphisa, the department acts against employees where necessary. "Complaints received from the public are presented, analysed, and monitored at different levels, and action plans get developed to inhibit future occurrences. Staff members who are found to experience issues," he says, "are referred to the Employee Assistance Programme within the facilities for further support. If that fails, disciplinary procedures get implemented through the labour relations process," he says.
He also reminded healthcare users and members of the public to forward their complaints whenever they are dissatisfied with its services. "Complaints can be presented to the operational manager of the clinic or they can deposit a written submission in the suggestion boxes placed in all clinics," he says.
Respect a 'two-way street'
Health authorities in the province have been outspoken about staff attitudes and the mistreatment of patients.
Speaking at an event held on International Nurses Day, KwaZulu-Natal Health MEC Nomagugu Simelane had a stern warning for nurses who mistreat patients. She told them to get their act together and stop tarnishing the image of the nursing profession. "Our nurses must never make patients feel like they're being a nuisance when they come to our clinics, Community Health Centres, and hospitals for help. At the same time, we are not saying that nurses must just roll over and allow people to abuse them. They must waste no time, but call security or law enforcement authorities, who must apply the relevant standard operating procedures when confronted by adverse situations. Respect is a two-way street," she said.
Some short-comings
But there were also some shortcomings flagged by Ritshidze. Among these are the "limited progress" made in filling staff vacancies, which is a key driver of long waiting times. The report notes that "81% of facilities [are] still reporting shortages and 449 vacancies [are] still open". Staff shortages have also been a common finding in Ritshidze's reports from other provinces.
Maphisa admits that some senior posts are still vacant due to budget constraints. "With regard to vacancies, not all posts have been filled. Some were filled with staff members who were employed on a contractual basis for COVID-19 and some, mostly senior posts, have not been filled due to budget constraints," he says.
Earlier this year, Simelane in her budget speech expressed concern that her department has to do more with less. She said budget cuts meant that they will have to cut back on certain services and this also poses a challenge for funding vacant posts.
According to Ritshidze, the filing systems at some facilities also still present challenges with missing files contributing to long waiting times. "This year only 76% of facilities were observed to have a properly functioning filing room, down from 81% last year. 12 facilities improved in the year, while 19 facilities got worse," the report states.
Regarding missing files, Maphisa says filing systems have been standardised throughout using the Health Patient Registration System (HPRS). He says no patient shall be sent home without medication or service. "All stable patients are registered onto the CCMDD programme (central chronic medication dispensing and distribution) where they can get their medication outside the health facility to avoid long waiting times and facility congestion. They are also referred to the PeleBox programme, which ensures that patients receive two months' ART supply," he says.
Poor services for key populations
One area where KwaZulu-Natal is falling short, according to the Ritshidze report, is in providing health services to key populations. "On the whole," the report states, "KwaZulu-Natal provided the worst services for key populations across all provinces monitored."
According to the report, only "28% of respondents reported that facility staff are always friendly and professional towards gay, bisexual, and other men who have sex with men; 19% towards people who use drugs; 16% towards sex workers; and 34% towards trans* people." Many of them said they did not feel comfortable, safe or protected from abuse and harassment at primary healthcare facilities.
The report shows that key populations often do not receive services specific to their needs. Among these were lubricants that were only available in 26% of sites monitored. Further, "only 41% of gay, bisexual, and men who have sex with men, 14% of people who use drugs, 31% of sex workers, and 59% of trans* people reported being offered PrEP at the facility," the report states. PrEP, or pre-exposure prophylaxis, is antiretrovirals taken to prevent HIV infection.
On access to healthcare for the LGBTQI+ community, Maphisa says, "The department has established an LGBTQI+ and youth clinic in eThekwini, which is already operational. For uMgungundlovu, the clinic has been established at City Central Clinic and East Boom CHC. The department is also in a process of procuring HIV prevention sundries that these communities use," he says.
Difficulty in accessing services
However, some organisations representing key populations that Spotlight spoke to, said the people they represent and support often are humiliated when they visit some clinics in parts of KwaZulu-Natal.
"When you are a sex worker and go to the clinic to collect condoms, you are often looked at in a funny manner or nurses will ask you what you are going to do with so many condoms," says Nokwande Gambushe, KZN Provincial Coordinator of the Sisonke National Sex Worker's Movement. The Sisonke movement is a non-profit organisation advocating for, among others, the decriminalisation of adult consensual sex work in South Africa.
Gambushe says sex workers often do not access health services where they stay because of a fear of discrimination. "Most sex workers are afraid to go to clinics in their communities because they are often discriminated against by healthcare workers and community members," she says.
According to her, some sex workers are also faced with challenges when trying to access reproductive health services such as termination of pregnancy because they do not have identification documents and proof of residence. "You will find that when a sex worker has to visit a public hospital for a termination of pregnancy, they are turned back because they do not have the necessary documentation. When they come back a month later, it is often too late to terminate the pregnancy because the legal period to terminate the pregnancy has expired."
However, Gambushe says there are mobile clinics in the province that provide other related services which they require.
While there has been clear progress in some areas, today's stories & data reveal the challenges that continue to make it hard for PLHIV & especially for sex workers, people who use drugs, & LGBTQIA+ communities to access health services #KZNHealth pic.twitter.com/JJtKyj63uT
-- Ritshidze (@RitshidzeSA) November 10, 2022
Name-called and misgendered
Sazi Jali, executive director of TransHope, a non-profit organisation that advocates for the rights of transgender and gender-diverse people in KwaZulu-Natal, also says discrimination at clinics is a problem.
"When members of the LGBTQI+ community visit public clinics in KZN, they face discrimination and they are name called. In some instances, you will find that transgender people are misgendered (being called male when one is a female).
"In most clinics, it is rare that you can find lubricants readily available as you find condoms in dispensers," says Jali. She believes that this situation needs to be improved.
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According to Ritshidze, lubricant was only available in 26% of the sites monitored. 19% of people who use drugs, 13% of sex workers and 36% of transgender people using public healthcare facilities said they could access lubricant.
When members of the LGBTQI+ community visit public clinics in KZN, they face discrimination and they are name called. In some instances, you will find that transgender people are misgendered (being called male when one is a female). - Sazi Jali, TransHope
TransHope has been assisting some clinics in Umlazi South with condoms and lubes, says Jali. She says it is important to ensure that lubricants are also provided in dispensers such as those for condoms because some people are afraid to go and ask for lubricants from nurses without being looked at funny.
However, Jali says private clinics such as the Aurum Institute's POP INN clinic in Durban provide adequate services. She would like to see this replicated at public clinics. These POP INN clinics offer free sexual health services to men who have sex with men and transgender women.
Gaps in access to hormone replacement therapy (HRT)
The Ritshidze report also flags limited access to gender-affirming care as a concern in the province. "In addition to the psychological impact of gender dysphoria, in the context of South Africa, a country rife with transphobia and attacks on trans* individuals, access to hormone therapy could mean life or death," the report states. "However, gender-affirming care is mostly only available in big cities and this keeps it out of reach for those without access to transport money and places to stay."
Ritshidze reports that 54% of trans* people interviewed said they wanted access to hormones at their facilities, "34% wanted outreach services for trans* people, 21% wanted trans* friendly STI prevention, testing and treatment, and 57% wanted access to psychosocial support services".
Meanwhile, Jali tells Spotlight, "In KZN we do not have a mainstream system for accessing gender-affirming healthcare. There are only a few doctors who have been trained in terms of treating transgender people and doing referrals to government institutions. Our organisation has been assisting people to transition medically by paying privately for people to see doctors and help them to access HRT (hormone replacement therapy). One consultation can cost up to R1 000 and then patients have to pay privately for HRT," she says.
