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Findings of a clinic monitoring report released last week, again highlighted how delivery of health services in the Eastern Cape are hamstrung by staff and medicine shortages.

The COVID-19 pandemic compounded these challenges.

This, the report says, also has far-reaching consequences for the province’s HIV and tuberculosis (TB) programmes.

The report is based on community monitoring conducted at 45 healthcare facilities across the Eastern Cape between April and June, with some additional monitoring in August and September. It is the latest in a series of such provincial monitoring reports published by Ritshidze, a community-led health service monitoring initiative. Spotlight previously reported on Ritshidze reports from the Free State, Limpopo, and the Northwest.

Not enough staff

The report found 133 vacancies in 28 clinics. According to facility managers interviewed as part of the monitoring, the most commonly understaffed categories were professional nurses, enrolled nurses, cleaners, doctors, enrolled nurse assistants, and assistant pharmacists.

Among the worst-performing clinics where patients and facility managers indicated there were not enough staff include Qumbu Community Health Centre, Mqanduli Clinic and Butterworth Gateway Clinic.

The report also notes a shortage of community health workers (CHWs) in some facilities and recorded challenges for CHWs to perform their duties. About 77{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of the facility managers interviewed cited lack of transport for CHWs as a major problem. “Of the facility managers reporting that transport was available, just five said that the transport was reliable,” the report states.

Since CHWs primarily work in communities outside the facilities, the report notes that “these findings reveal an important barrier to the efficacy of the CHW programme in the province”. Other challenges flagged were safety concerns for CHWs working in communities, not enough phones and that patients give wrong numbers. The CHWs are crucial in tracing people living with HIV and TB who have interrupted treatment.

A need for male nurses and councillors

The report also flagged a shortage of male nurses and counsellors at many facilities and that male-specific health services were limited – factors thought to contribute to men being less likely to seek healthcare services.

The Ritshidze data found that only 61{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of the monitored facilities reported having male nurses, counsellors, or healthcare workers at the facility. “Of that 61{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c}, only 27{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of facilities said they had male outreach services and 9{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of facilities said they had no male-specific services at all,” the report states.

One healthcare user, Nkosekhaya Gidi from Motherwell, tells Spotlight, “As men, we have that problem of thinking that clinics are meant for women. Men by nature are not willing to share their medical issues with women because when growing up [they’re made to believe] men are always strong. There is no need to see a doctor or a nurse even when one has pain [because] that pain will improve on its own.”

Gidi says having male nurses will definitely help.

A community healthcare worker at Motherwell Clinic suggested that people must forget about the older generation of men and shift the focus to the young people to educate them about the importance of visiting clinics.

“The first thing is to visit boys at primary schools to change their mindset and encourage them to share and open up about their feelings. We all need to address the stigma associated with men visiting clinics, not to mention the pressure of a man that they are always strong. The department needs to strengthen campaigns towards men and must visit their workplaces to talk about these health issues,” the community health worker said.

At Motherwell, the CHW says they have one male nurse and one male CHW serving the area.

Mkhululi Ndamase, spokesperson for Eastern Cape Health MEC Nomakhosazana Meth, tells Spotlight there are “mechanisms [already in place] to respond to many of the issues highlighted in the Ritshidze report. This, he says, includes programmes where the department is taking health services directly to where people live, work, and spend recreational time.

“This is to encourage men to look after their health.”

Big asks but little money

According to Ndiphiwe Bekwaphi, a Ritshidze District Organiser from the Treatment Action Campaign (TAC), these factors along with medicine stockouts “directly contribute to people living with HIV starting and staying on treatment, and can be linked to the province only attaining 72{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of people living with HIV who know their status on treatment”.

The report argued that “ensuring access to quality healthcare services and ensuring everyone living with HIV and TB gets access to medicines and care, depend mainly on having enough qualified and committed staff” so, “ensuring that 80{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of vacancies at facilities are filled by March 2022, must be a priority in this province”.

But in July this year, the now-suspended spokesperson for health in the Eastern Cape Sizwe Kupelo cited budget constraints preventing the department from appointing the much-needed staff. Kupelo then said a recruitment process was at “an advanced stage for [appointing] 86 frontline workers”. “These are professional nurses, enrolment nurses, and assistant nurses. They will be placed on a needs basis with clinics and hospitals in desperate need of more workers,” he said.

The superintendent for health in the province, Dr Rolene Wagner this week in an interview with ENCA again cited budget constraints that are now also affecting paying for the basics in goods and services needed at health facilities.

Spotlight asked the department about its plans to address staffing challenges in primary healthcare facilities but did not receive a response by the time of publication.

Medicine shortages

The report also found that in many facilities, patients arrive early in the morning and many would spend the entire day waiting, but are often forced to go home empty-handed. According to the report, this is a consistent and significant cause of dissatisfaction among healthcare users at these facilities.

“Ritshidze monitoring reveals ongoing complaints regarding stockouts and shortages of medicines, and medical tools at sites across the Eastern Cape,” the report notes. Across the facilities monitored, data shows “9{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of people left, or knew someone who left a clinic without the medication that they needed”. “Stockouts and shortages of ARVs, TB medicines, contraceptives, and other medicines,” the report states, “cause disruption, confusion, cost, and can detrimentally affect treatment adherence.”

The most commonly reported medicine shortages cited by patients included contraceptives, HIV medicines, and pregnancy tests. Facility managers interviewed also noted the most common stockouts were of contraceptives and HIV medicines. Almost two-thirds said in case of stockouts they provided patients with alternative medicine, 9{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of them were forced to send people away empty-handed, and 24{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} gave patients a shorter supply.

Among the worst medicine stockout challenges were flagged in OR Tambo and Alfred Nzo Districts. Clinics monitored in these two districts with low scores for medicine stock include the Matatiel, Qumbu, Ngangelizwe, and Maluti Community Health Centres. In July, the Daily Dispatch reported that the province was running out of medicine supplies due to the non-payment of suppliers. It was reported that Sanofi, a pharmaceutical company that supplies the Eastern Cape with essential medicines, including TB, epilepsy, anti-psychosis, and diabetes medication, suspended its supply to the province in March due to non-payment.

But according to Ndamase, the department remains committed to ensuring that there’s enough stock of essential medicines for HIV, TB, and other medications. “Government has prioritised the budget for medicines because it is one of the ‘non-negotiable’ budget lines. This means the budget for medicines has been ring-fenced and cannot be used for other services.”

Ndamase says in the 2019/20 financial year, the budget for ARVs and drug-susceptible TB was R936 700 000, in 2020/21 it dropped to R907 323 000, and in this financial year the department allocated R1 278 700 000 for ARVs and TB medicine.

“When supply shortages do arise, they were caused by the COVID-19 pandemic that caused disruptions of global supply chain systems, with local manufacturers struggling to source raw materials from international markets. This was out of our control,” said Ndamase.

Impact on HIV

The report highlights the risk of having people living with HIV spend an extended time at a clinic simply to collect ARV refills. This, it states, increases the risk of people disengaging from care.

At Motherwell Community Health Centre, it is reported that patients spent on average seven hours, including waiting for it to open, only to be seen for a very short consultation.

A community healthcare worker (CHW) at Motherwell Community Healthcare Centre agrees that the facility often experiences very long waiting times.

Speaking on the condition of anonymity, the CHW says, “The issue of long queues is caused by an increase in population and is worsened by some people who prefer this facility while leaving their clinics where the situation is worse. The clinic is too small to serve the growing number of patients. The department needs to take into consideration that Motherwell is fast-growing,” says the CHW.

“The waiting time and patient flow can be managed if the department could strengthen its chronic disease management plans. This involves empowering individuals to take responsibility for managing their own conditions and increasing awareness of chronic diseases. There should be a strengthening of support systems and structures outside the health facility process to ensure a fully functional and responsive healthcare system.

“Health education and health promotion at the household level will reduce the need for clinic visits and lessen pressure on clinics. If the department could convert these vaccination campaigns into chronic disease campaigns, we will see fewer people visiting clinics.”

Multi-month dispensing

The report found that although “61{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of people living with HIV reported receiving two month ART refills, only 15{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} reported three month ART refills, which is low as the country aims to move towards longer multi-month dispensing”. Further, “21{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of people living with HIV still reported refills of one month — which is very problematic considering that South Africa’s national policy standard is for two months,” the report states. “It is also worrying during the period of COVID-19 when refills should be longer to ensure people living with HIV can make fewer trips to the clinic.”

The report notes that all the facilities monitored reported having internal pickup points available and 91{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} had external pickup points for people living with HIV.

Most patients were satisfied with the internal and external pickup points.

21{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of PLHIV interviewed received 1 month supply of ARVs – while national policy standard is 2 months. Only 15{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} received 3 months supply. Compared to other @PEPFAR countries where 75{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} of PLHIV received 3-6 month supply. We need longer treatment supplies! #EasternCapeHealth pic.twitter.com/zAaecYONIR

– Ritshidze (@RitshidzeSA) September 23, 2021

Provincial health department’s plan

According to Ndamase, the department has the Centralised Chronic Medicines Dispensing and Distribution (CCMDD) system as an alternative strategy for stable patients to access chronic medication. “Any of our facilities can register patients for CCMDD and give them a six months repeat prescription. Patients can choose any of the contracted pickup points to collect their medication.”

Ndamase tells Spotlight the province has 4 596 CCMD pickup points. Rural districts such as Alfred Nzo District has 348 of these pickup points, there are 573 in Chris Hani District, Joe Gqabi has 79, OR Tambo District has 982, and the Amathole District has 828 pickup points. According to him, this means there are 2 810 of these pickup points in the rural areas with the rest in more urban districts such as Sarah Baartman (117), Nelson Mandela Bay (609) and Buffalo City (1 060).

“This,” he says, “allows patients who are on chronic medication to collect their medicines outside the health facility at pick-up points closer to their homes – either pharmacies or general practitioners’ rooms. Over the past few months, the province has maintained an above 80{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} availability of essential medicines and over 90{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} for medicines for HIV treatment.”

Ndamase says by 31 August this year, there were 264 362 patients in the province collecting their medicines on a regular basis through the CCMDD programme. The breakdown per district shows the biggest uptake was 73 685 patients in the OR Tambo District and the lowest uptake (7 264) in the Joe Gqabi District.

“Where there are stock-outs, these have been due to system challenges. When staff contracted COVID-19, it placed a huge strain on our capacity. There was, regretfully, also miscommunication on how to access medicines when facilities were closed for decontamination in the early months of the pandemic. Such issues have all been addressed as we had to learn quickly during the surges,” says. Ndamase.

Note: A representative of the TAC is quoted in this article and 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. Spotlight is a member of the South African Press Council.