According to the latest report from community-based clinic monitoring group Ritshidze, users of public sector health facilities in Mpumalanga are experiencing shorter waiting times, cleaner facilities and extended antiretroviral refills compared to previous years. But Ritshidze also reports ongoing staff shortages, problematic staff attitudes, and problems with infrastructure.
These challenges were aired in community meetings held on 13 and 15 June in Kabokweni and Ermelo where Ritshidze presented the third edition of their Mpumalanga State of Health report. Provincial health department officials, community members, and various stakeholders in the health sector attended the meetings. Ritshidze's first report was published in May 2021 and the second in June 2022. Similar to earlier editions, the latest edition outlines key challenges faced by people living with HIV, key populations, and other public healthcare users when visiting clinics. The reports all focus on staffing, waiting times, ART collection, ART continuity, treatment, viral load literacy, accessibility and friendliness of health services for key populations, and TB infection control measures in clinics.
For this edition of the report, Ritshidze monitored 43 facilities across Mpumalanga - 21 in Ehlanzeni District, 18 in Gert Sibande District, and four in Nkangala District. Data for the new report was collected between April and May 2023 and they interviewed 43 facility managers. Their observations were recorded at the 43 facilities, where they interviewed 2 320 public healthcare users. Around half of the respondents are living with HIV and roughly a quarter are aged 25 or younger.
Staff shortages
According to the report, only 35% of facility managers interviewed believed that there are enough staff at the clinics where they work. There were 117 unfilled vacancies reported across 25 facilities. Spotlight reported in March that the provincial department - despite shortages and a clear need for extra hands, also in clinics -underspent its budget for employee costs in the third quarter of the 2022/2023 financial year. Spending, however, did improve by the end of the financial year after the department appointed some additional personnel. The department attributed this underspending to the "challenges of attracting new health workers across categories to the province".
It is, however, not clear how the department intends to walk the tightrope between budget constraints and the prevailing difficulties in attracting healthcare workers to a mostly rural province.
When Spotlight asked provincial health spokesperson Dumisane Malamule how the department plan to address the staff shortages, he said the department on an annual basis "identifies and funds critical vacancy lists with the aim of strengthening the public health system for each year".
"For the 2023/24 financial year, the department has set aside over R217 million, which is aimed at strengthening primary healthcare clinics, contracting doctors, revenue collection, the appointment of pharmacy support personnel, malaria eradication, strengthening emergency care support, and appointment of infrastructure personnel," he says.
Malamule says the main focus of the department is to ensure that core support personnel are appointed on time to address challenges of long turnaround times so that they can offer patients immediate access to medical and pharmaceutical support.
At the primary healthcare level in clinics, facility managers (operational managers) are a core component of the efficient functioning of clinics and they are among the key roleplayers in decision-making for getting clinics to 'ideal status' as required for South Africa's proposed national health insurance system. Yet, the department's fourth quarter performance report for 2022/23 - that is the period from December 2022 to March 2023 - showed that there were 30 clinics across three districts without these crucial managers. In the Ehlanzeni district, seven clinics were without operational managers, in Gert Sibande four, and in Nkangala District 19. According to the department, recruitment processes were underway.
By the end of the last financial year (March 2023), only 195 of 292 primary healthcare facilities in the province had attained 'ideal status' where they comply with certain criteria including adequate staffing levels, the fourth quarter performance report shows. This was because there were, among others, not enough PHC nurses trained in basic life support or "professional nurses trained on Adult Primary Care and practical approach to care in each PHC facility" and because "most clinics did not have pharmacist assistants". These are all essentially operational management issues that can hamstrung quality service delivery.
Since the first of these monitoring reports in 2021, Ritshidze recommended that the Mpumalanga Health Department produce an annual report on the number of healthcare workers per category employed in each district, which should include the number of people and size of areas covered by these healthcare workers, year-on-year with comparisons (from at least 2021), the vacancies, and the cost of these posts to the government.
According to Malamule, they have indeed produced lists of filled vacancies, funded, and vacant posts. Spotlight reported on some of these human resource challenges here.
When Spotlight spoke to Ritshidze's Project Officer, Ndivuwho Rambau she explained that there are ongoing consultations with the provincial health department but this year they failed to meet with the new Head of Department Dr Khetani Lucas Ndhlovu and the health MEC because they were busy with plans to present the budget speech at the provincial legislature. "We are scheduled to meet with the provincial leadership so that they can account in terms of our recommendations relating to staff shortages. If our needs are not met, we will be forced to take to the streets with various advocacy groups," says Rambau.
According to the Democratic Alliance's head of research in the province, Ashleigh Trichardt, the department does not have a concrete plan to deal with staff shortages as they are affected by litigation orders and costs, which results in their being less money for operational costs. "The department is unable to budget for these litigation orders and costs as it is against the Public Finance Management Act (PFMA). So when they receive an order, they have to find the money elsewhere," Trichardt said.
Mpumalanga's Health MEC, Sasekani Manzini in her budget speech tabled earlier this month, said the department will appoint 65 additional pharmacist assistants in primary healthcare facilities. The process started in March this year and appointments will be done in the first quarter of the 2023/24 financial year with a budget of R19 million, she said.
Poor infrastructure and clinic conditions
Ritshidze found that 79% of the facilities monitored required additional space while 26% of facility toilets were in a bad condition where there was no toilet paper or soap. Ritshidze recommends that the department should carry out an audit of all facilities to assess infrastructural challenges. After which, the department should develop a plan in order to renovate buildings and ensure adequate space to provide efficient, private, and safe healthcare services.
These observations are also reflected in the fourth quarter performance report. The report, among others, flags the "inappropriate storage of healthcare risk waste in most health establishments, pest control [that is] not done in most health establishments, and the lack of back-up water and electrical supply in most primary healthcare facilities".
When visiting clinics in Mpumalanga, Ritshidze found that only 56% of facilities had a working generator and that, in some instances, diesel runs out.
When asked about this, Malamule said that all facilities have generators and R83 million has been allocated in this financial year to ensure that they have enough fuel.
Malamule also said that the department has appointed the Council for Scientific and Industrial Research (CSIR) to conduct an assessment of all facilities across the province and provide cost estimates for backlog maintenance and replacement of facilities that need to be replaced. "We are also appointing plumbers to establish our maintenance hub for day-to-day maintenance," he said. Despite repeated requests for timeframes for this, he did not provide any.
Health MEC Manzini in her budget speech said they plan to build seven new clinics, including Dumphries Clinic, CN Cindi Clinic, Ermelo Town Clinic, Troya Clinic, Casteel Clinic, Driekoppies Clinic, Msholozi Clinic, and they will upgrade Siyabuswa CHC to a larger facility to accommodate more services.
"The department has set aside a budget of 11% (R 206 409 000) of the total infrastructure allocation for maintenance of health facilities to ensure that health facilities are accredited to the Ideal Facility programme," she said. "To improve the image of health facilities and patient experience of care, 40 Facilities are identified to benefit [from] the building maintenance programme at a budget of R 68 460 000."
Manzini also said that to ensure quality care to public healthcare users, the department has prioritised "a preventative routine maintenance servicing and repairs of life-saving equipment programme and that maintenance is done as per manufacturer requirements". R138 million has been allocated for this. She also said that 59 community health centres and 22 clinics will be prioritised in a budget allocation of R83.5 million for diesel to mitigate the risk of loadshedding.
Poor staff attitudes
According to Ritshidze, privacy violations and poor staff attitudes continue to occur at clinics they monitored in Mpumalanga. This, the report states, destroys people's right to privacy and makes clinics feel unsafe and uncomfortable to be in, often leading patients to interrupt their treatment.
"The nurses there discuss your problem and what you came there for. My medical issues are supposed to be private, but they discuss it amongst each other like I am not there. There is no privacy in the consultation rooms at all," a sex worker using Nelspruit Clinic in the Ehlanzeni District said during one of the community meetings.
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This year, 49% of gay, bisexual and men sleeping with men (GBMSM), 54% of people who use drugs, 37% of sex workers, and 34% of transgender people did not think privacy is well respected at clinics.
Malamule told Spotlight that the department is continuing with sensitisation training and ensuring that Batho Pele principles (government service standards) are adhered to. This was an undertaking by the department since the first Ritshidze report.
In the latest report, Ritshidze recommends that any reports of poor staff attitude, privacy violations, verbal or physical abuse, harassment, and services being restricted or refused should be urgently investigated.
The provincial department's third quarter (2022/23) performance report tabled in the Mpumalanga legislature's health committee showed that budget and human resource constraints often led to delays in the investigation and finalisation of disciplinary hearings. By the end of the 2022/23 financial year (March this year), only ten of 65 misconduct cases have been finalised and three of 11 suspensions finalised.
Increase in duration of ART refills
Ritshidze data reveals the duration of ART refills is increasing, with the majority of people living with HIV (64%) interviewed by Ritshidze now receiving three to six months' supply at a time. Longer refills mean people have to visit clinics or other pickup points less often.
Mpumalanga scored best on this indicator out of all provinces monitored by Ritshidze. However, their numbers are low compared to a basket of 21 other countries, where 80% of people living with HIV received 3 to 6-month ART refills between October and December 2021. (The 21 countries, like South Africa, all receive support from PEPFAR - the United States President's Emergency Plan for AIDS Relief.)
In the report, Ritshidze cites figures from the national health department's national central chronic medicines dispensing and distribution (CCMDD) data for 2022 that shows the number of people living with HIV and receiving a three-month supply has decreased from 175 404 to 109 303 in Mpumalanga over the year.
Manzini in her budget speech also made some undertakings to improve medicine availability. "The department plans to improve average medicine stock availability within all healthcare facilities from 83% to 95% and above by procuring an integrated medicine management system which will interface the medical depot and health facilities with a budget of R50 million," she said.
