South Africa: Report Finds Some Improvement At Mpumalanga Clinics, but Serious Challenges Remain

A year after the first clinic monitoring report highlighted several challenges in some Mpumalanga clinics, some patients still say they sometimes spend over four hours waiting to be seen at these facilities and suffer abuse at the hands of healthcare workers.

The community-led clinic monitoring project, Ritshidze last week released its follow-up report on the state of (primary) healthcare in Mpumalanga.

While there has been an improvement in waiting times, declining from 4:33 hours to 4:05 hours over the last year since the first report, this “remains an extremely long time for public healthcare users to wait at the facility to only be seen for a limited time,” the report states. There is also a concern that “having people living with HIV spend an extended time at a facility, simply to collect ART [antiretroviral therapy] refills, also increases the risk of that person disengaging from care”.

Out of the 1 833 public healthcare users interviewed, the majority said that waiting times at clinics in Mpumalanga are long. The percentages varied across different districts, with 76% in Gert Sibande District, 65% in Nkangala District, and 56% in Ehlanzeni District. Some of the reasons for the long waiting times are messy or lost files (37%), staff shortages (31%), and staff not working or dragging their feet (31%).

Some healthcare users relayed their experiences to clinic monitors.

“I go to Khumbula Clinic. They don’t treat us well. We arrive early in the morning and leave late around 2 pm. I no longer collect my treatment. I want to go back but because of the mistreatment there, I stopped going. They see me as a nobody,” says one healthcare user.

“It hurts to feel less important in the community or clinic because we spend the whole day moving from one bench to another, only to be told that they cannot help you. You don’t even have money to buy an orange. You are hungry and spend the whole day there,” says another healthcare user.

Data for the report was collected between April 2022 to May 2022. They monitored 42 facilities.

Some improvement

Last year, Ritshidze reported that only 7% of facility managers at clinics in Mpumalanga said they had enough staff. In this year’s report, this number has increased to 41% of facility managers at clinics who said they have enough staff. While certain improvements have been made, there is still a human resources gap, the report states. This year, 54% of public healthcare users said there are always enough staff (up from only 30% last year).

The report also shows that there is a surge in the number of unfilled vacancies across facilities monitored in the previous year. Although the department has started to fill these vacancies, there are still 97 vacancies across 17 sites. The most commonly reported vacancies are for enrolled nurses, professional nurses and doctors.

“The Mpumalanga Department of Health committed last year to fill all vacancies and prioritise 476 critical posts for the 2021/22 financial year, which were to be advertised and filled in different phases of that financial year,” the report states. “While there have been positive improvements across facilities monitored in the province, a clear gap still remains between the staffing needed to ensure high-quality services and the staff present each day at site level.”

Last year, 74% of the facilities that Ritshidze monitored had filing systems that were in a bad state. This year there was some improvement as the number dropped to 38% of facilities with filing systems that are messy. Among the facilities that need to improve their filing systems are Amsterdam CHC, Bethal Town Clinic, Embalenhle CHC, and Ermelo Clinic, among others. Files that are orderly and readily available are crucial in keeping waiting times low.

A patient interviewed, who spoke on condition of anonymity due to fear of reprisal, said sometimes when they arrive, “your file is missing and they say you must start a new one”. He says this new file issued does not have your patient history. “I take treatment at a clinic in Extension 14. I have never seen my file. They only issued papers even when I do blood tests, they never explain the results. When I moved to a private pharmacy to collect my treatment, they didn’t explain what time I should take my pills or the colour of my treatment is different,” says the patient.

Low satisfaction rates

According to Ritshidze, Mpumalanga is flagged as a particularly concerning province since its public healthcare facilities had the lowest satisfaction rates among interviewees, who reported that these facilities had the least friendly and professional services.

According to the DA’s health spokesperson in the province, Jane Sithole clinics and community healthcare centres are barely functioning due to long overdue maintenance ranging from dysfunctional geysers, leaking roofs, and broken water pumps – forcing nurses to collect water in buckets to clean clinics.

“Communities are continuously complaining that the healthcare workers are in the wrong or not doing their jobs. What the communities don’t know is that it is not their fault, but it’s actually the MEC and the officials in the department who are failing to deliver on the basics to ensure clinics have things such as medicine and rotational doctors,” says Sithole.

Sithole says departmental health officials don’t have to face patients and their families, but it is healthcare workers who must face the wrath of angry family members and it is understandable why healthcare workers are negative at times towards patients.

According to the report, 26% of facilities monitored were in a bad condition last year, 89% of facilities needed some additional space, 40% of facilities did not have enough room in the waiting area and 58% of facility toilets were in bad condition. This year Ritshidze recorded the same number-26%-of facilities that are still in a bad condition and more facilities (58%) did not have enough room in the waiting area.

The department responds

Responding to questions on staffing, provincial health spokesperson Dumisani Malamule says the department is employing more nurses to reduce long waiting hours at clinics. He says the Buffelspruit Clinic is, however, experiencing long waiting hours due to the fact that the clinic is under renovations and a mobile clinic has been set up to render services. “Posts are being advertised every now and then and filled accordingly. We also have Mpumalanga Nursing College, where more than 500 nurses graduate every year and they are placed in clinics around the province,” he says. According to him, the department absorbs all these graduates but the DA says many doctors and nurses prefer the more urban provinces such as Gauteng for work.

Regarding poor staff attitudes flagged in the report, Malamule says, “Training on customer care is being provided to our staff members. The department also monitors their behaviour and always encourages patients to report any misbehaviour by staff as soon as possible. Strict disciplinary action is also being taken against those that do not comply with patient care,” says Malamule.

A huge chunk – R10 billion – of the Mpumalanga Department of Health’s R16 billion budget for this financial year is allocated to district health services, which clinics fall under. While tabling the 2022/2023 budget, Health MEC Sasekani Manzini said her department is determined to increase access to health services. This, she said, is done through deploying mobile clinics to augment the 292 primary healthcare facilities, particularly in remote and farm areas. The department has 92 mobile clinics with 2 186 points that service these remote areas, she said.

“There is still a need for 65 additional mobile clinics to replace and add to the current fleet. However, due to budgetary constraints, the department has prioritised procurement of 17 mobile clinics in the 2022/23 financial year to assist in sustaining the service, with an estimated cost for the additional mobile clinics which is R19 million,” Manzini said.

51% of Ritshidze observations found that toilets were in bad condition: 69% in Gert Sibande, 50% in Nkangala, and 37% in Ehlanzeni. Mostly toilets did not have toilet paper or soap, or were dirty #MpumalangaHealth #ClinicsInCrisis pic.twitter.com/zse96mV5sq

— Ritshidze (@RitshidzeSA) June 23, 2022

She said her department has received requests and demands from some sectors of the province to increase the operating hours of clinics to 24 hours.

But according to Manzini, she has not yet granted permission for the increase of hours of any facilities in line with the National Norms and Standards. The National Norms and Standards provide clear directives on the categories of health establishments taking into account population distribution.

According to the Ritshidze report, “none of the non-24-hour facilities are reported as opening by 5 am on weekdays and only two non-24-hour facilities were reported as opening by 8 am on Saturdays”.

Manzini said she is “fully aware that some of these clinics’ infrastructure struggle to meet the demand of the community”.

“In the recent years, we have observed a high rate of mushrooming communities that demand to have fixed structures even if they do not qualify to have one due to population size. These pose a challenge for us because most of the new areas are highly scattered,” she said. According to her, the department has developed an infrastructure plan “on envisaged construction of health facilities in areas that do not have fixed structures”. “The department has also developed a five-year Provincial Infrastructure Improvement and Maintenance Plan that is aligned to the Ideal Clinic initiative informed by district plans,” she added.

Manzini said the budget for maintenance and improvement of infrastructure is not enough as R10 million has been put aside for clinics earmarked to be Ideal Clinics.

65% think waiting times at the facility are long. Varied across districts: 76% in Gert Sibande, 65% in Nkangala, & 56% in Ehlanzeni. Most common reasons: messy/lost files (37%), staff shortages (31%), staff not working/working slowly” (31%) #MpumalangaHealth @TAC pic.twitter.com/j7LNe8Sgvr

— Ritshidze (@RitshidzeSA) June 23, 2022

Towards fixing primary healthcare

Professor Helen Schneider, a public health specialist and health system policy researcher says ensuring that there is competent leadership within the sector is important to maintain stability and deliver services to communities.

“Government should ensure that those who are in leadership positions are equipped with the necessary skills and knowledge. It is important that there is a culture shift where patients and healthcare workers are put first,” says Schneider.

She says that further political initiative is required for resources in the health sector to be used properly despite the economic climate. Schneider says that there is incredible work being done despite the austerity measures in place within the government sector. “It is gratifying to see that there were improvements recorded, although we are far away from achieving a people-centred health system. Independent citizen scorecards can achieve the desired change and initiatives such as Ritshidze will help to improve the health system,” says Schneider.

Russell Rensburg, director of the Rural Health Advocacy Group (RHAP), says it is also important to invest in rural healthcare because rural areas are the places where most of the people who require medical attention in the country reside but the healthcare system in these areas are weak.

“It is important to deploy community healthcare workers in rural areas to ensure that people can access health services like testing and access to chronic medication,” says Rensburg.

He says most people in rural areas do not have the correct information on which health services they can access and where they are accessible, which then creates a barrier to utilising the system to its full capacity. “It is equally important for health departments to ensure that they conduct regular surveys to see where their shortfalls lie,” he says.

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