On Wednesday, a patient arrived at the closed gates of Madimbo Clinic in Mutale in the Vhembe district at about 5.30am, according to a statement from DA spokesperson for health in the province, Risham Maharaj. The patient was “kept outside waiting for medical attention” for an hour and a half because a nurse at the 24-hour clinic allegedly told her they only opened at 7am.
The patient was then referred to the Donald Fraser Hospital in Vhufuli Tshitereke village, Thohoyandou, which is about 90km away.
On the same morning at the same clinic, another patient reportedly went into labour in front of the closed gates.
Limpopo department of health spokesperson Neil Shikwambana confirmed the incidents and said Spotlight emergency medical services had taken both women to the Donald Fraser Hospital, where the mother delivered a healthy infant, but the other patient died that evening.
He said that the department was still investigating the incidents and the nurse who was on duty at the clinic had since been suspended.
According to the Ritshidze report, almost 70% of the 385 individuals interviewed for the project said there were not enough staff at clinics in Limpopo to meet patients’ needs. Activists said this also meant long waiting times for patients and overworked personnel, which could ultimately undermine the province’s HIV programme.
The report, released on August 26, was based on the monitoring of 17 clinics and community healthcare centres in Limpopo between April and June this year.
Short-staffed and unsafe
Too few staff – particularly professional and enrolled nurses in clinics, as well as pharmacists and cleaners – was one of the big challenges flagged in the report. It noted at least 30 vacancies across the 17 facilities. More than 90% of the facility managers interviewed said that insufficient human resources were among their biggest obstacles.
At nine clinics, patients reported average waiting times of four hours or longer and at four clinics, some patients said they waited an average of five hours or longer to be seen by healthcare workers.
Of the patients interviewed, 51% reported feeling very unsafe waiting for clinics to open.
“Early mornings, feeling unsafe outside the clinics and long waiting times cause people to dread clinic days, or even stop going. This directly impacts on our ability to reach 95% of people living with HIV on treatment,” the Ritshidze report read.
It pointed out that a circular issued by the department of health in 2019 had instructed facility management that these public health facilities “must be open from 5am to 7pm, as well as from 8am to 4pm on Saturdays”. The report asserted that these opening times were not possible in many of the facilities due to staff shortages.
The department responds
Shikwambana said that although there were 24-hour clinics in the province, some had had to close due to safety and security issues. He acknowledged that staff shortages were a big concern.
“We’re working on a human resources structure that will speak to our service needs,” he said, adding that the department had initiated a “turnaround plan two or three years ago”.
According to Shikwambana, the department’s salary bill was about two-thirds of its entire budget.
“So we may have shortages, but the salary bill shows the workers are there,” he said. “We may have a high vacancy rate, but, in reality, on the personal and salary system, we have a lot of personnel.”
He also said the department was making its management structure less top-heavy and had reduced its number of deputy directors-general from six to four. When people retired, said Shikwambana, positions were rationalised so that senior personnel got additional responsibilities.
He stressed, however, that there was only so much the department could do because it needed organised labour on board.
Asked when healthcare users who depended on these clinical services would see a difference in staffing levels, Shikwambana said: “We can’t make commitments. It depends on processes. It’s a complex issue.”
The Limpopo health department’s annual report for 2019/20 shows that by March 31 last year, there were 44 924 approved posts in district health services, but only 23 024 of these positions had been filled at the time, which meant a vacancy rate of almost 50% for district health. The vacancy rate for professional nurses in the province stood at 35%.
Under “desired service standards”, the department’s annual report noted that it needed to improve “timeous payment of suppliers to ensure sustained supply of medicines for 12 months in a financial year, decongest facilities to effect friendlier services (utilising a central chronic medicine dispensing and distribution programme), improve stock management, planning and forecasting to effect continuous supply of essential medicines, as well as improve human resource utilisation to extend hours of service”.
What happened, however, as reported by the department, was that “medicine availability has been below target at all levels due to some of the essential items not being awarded on new national contracts”.
According to the Ritshidze data, 38% of patients interviewed “left, or knew someone who had left, a clinic without the medication they needed”.
Most patients mentioned contraceptives having been out of stock, but some also reported having left the clinic without HIV and TB medicines. Facility managers who were interviewed said that when the clinics experienced stockouts, in “50% [of cases, they] were forced to send people away empty-handed and [in the remaining] 50% of cases, [they gave patients] an alternative”.
At some facilities, such as Perskebult Clinic in Polokwane, HIV medicine was the biggest challenge. At the Grace Mugodeni community health centre, contraceptive stockouts were also flagged. Perskebult and the clinic in Ga-Mothapo village, Polokwane, received the worst scores for stockouts.
“Shortages of antiretrovirals, TB medicines, contraceptives and other medicines cause disruption, confusion and cost, and can detrimentally affect treatment adherence,” the Ritshidze report read.
It recommended that the department develop a “provincial strategy to address stockouts and shortages of medicines and other medical tools and supplies” by February.
Shikwambana told Spotlight that the stockouts were not unique to Limpopo, but were common across the country’s provinces.
“There are often issues with medicine suppliers and we also rely on international medical markets. We’re not trying to shift the responsibility, but there are many factors at play in medicine supply,” he said.
He added that the department would work through the contents of the Ritshidze report and would then decide on the best way forward.
The provincial department of health flagged the “courtesy of healthcare workers” as a concern in its annual report. It reported that it had a “complaints management system” that enabled it to monitor whether patients were treated respectfully, and acknowledged that there had been “a few incidences of negative attitude towards patients”, but said the issue had been addressed.
The Ritshidze report, however, painted a different picture, highlighting “the discriminatory and insensitive attitude” some nurses and clinic staff had towards key populations, “including sex workers and members of the LGBTIQ+ community”.
According to Sibongile Tshabalala, chairperson of the Treatment Action Campaign (TAC) – which was one of the partner organisations in the Ritshidze project – the data showed that these negative staff attitudes were among the reasons the province was unlikely to reach UNAids’ “95-95-95” targets (a strategy aimed at 95% of people living with HIV being aware of their status, 95% of those knowing their status being on antiretroviral therapy and 95% of those on treatment being virally suppressed – all by 2025).
According to the report, while 91% of people living with HIV knew their status in Limpopo, only 73% of them were on antiretroviral medication and 87% of that group were virally suppressed.
On the Ritshidze blog, Tshabalala wrote: “Only 57.9% of patients thought the staff were always friendly and professional. This lack of professionalism and bullying attitudes by some nurses have come to define the experiences of many patients reliant on Limpopo’s clinics. We need a clear strategy to change this, as it inflames tensions between communities and their local healthcare workers. Most devastatingly, it’s removed trust and confidence in the healthcare system and has had dire impacts on patients’ care.”
The report found that of people living with HIV who were surveyed, 59% said staff at clinics shouted at them if they missed an appointment, while 12% said they had been sent to the back of the queue for missing an appointment.
“Anything that has the ability to derail the province’s efforts against HIV is concerning,” wrote Tshabalala. She encouraged people in rural areas especially to use the department’s complaint processes to report such incidents.
Note: A representative of the TAC is quoted in this article. The TAC is part of the Ritshidze project.
Spotlight is published by Section27 and the TAC, but is editorially independent, an independence that the editors guard jealously. Health journalism in the public interest