The provincial Health Department in Mpumalanga has responded to the third report from community-based clinic monitoring group Ritshidze on public health facilities in the province, writes Nthusang Lefafa in Spotlght.
While shorter waiting times, cleaner facilities, and extended ARV refills were some of the positive points highlighted, there are still ongoing staff shortages, problematic staff attitudes, and infrastructure issues as were aired in community meetings held earlier this month in Kabokweni and Ermelo where Ritshidze presented the third edition of its Mpumalanga State of Health report.
Its first report was published in May 2021 and the second in June 2022, and similar to earlier editions, the latest document outlines key challenges of people with HIV, key populations, and other public healthcare users, when visiting clinics.
Challenges include staffing, waiting times, ART collection, ART continuity, treatment, viral load literacy, accessibility and friendliness of health services for key populations, as well as TB infection control measures in clinics.
For this edition, Ritshidze monitored 43 facilities across Mpumalanga, interviewing 2 320 public healthcare users. Around half have HIV and roughly a quarter are 25 or younger.
Staff shortages
Just 35% of managers interviewed believed there are enough staff at the clinics where they work. There were 117 unfilled vacancies in 25 facilities.
While the provincial department underspent its budget for employee costs in the third quarter of the 2022/2023 financial year, spending improved by the end of the financial year after it appointed some additional personnel.
It is not clear how the department intends to balance budget constraints and the difficulties of attracting staff to a mostly rural province.
When Spotlight asked provincial health spokesperson Dumisane Malamule about plans to tackle staff shortages, he said on an annual basis, the department “identifies and funds critical vacancy lists”.
“For the 2023/24 financial year, more than R217m has been set aside to strengthen primary healthcare clinics, contract doctors, for revenue collection, appointing pharmacy support personnel, malaria eradication, strengthening emergency care support, and appointment of infrastructure personnel,” he said.
A major focus was to ensure core support personnel are appointed on time to address challenges of long turnaround times so patients can get immediate access to medical and pharmaceutical support.
At the primary healthcare level in clinics, operational managers are a core component and among the key roleplayers in decision-making for getting clinics to “ideal status” as required for South Africa’s proposed NHI system.
Yet, the department’s fourth quarter performance report for 2022/23 – from December 2022 to March 2023 – showed 30 clinics across three districts were without these crucial managers. In the Ehlanzeni district, seven clinics were without operational managers, in Gert Sibande four, and in Nkangala District 19.
By the end of the last financial year (March 2023), only 195 of 292 primary healthcare facilities 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 had recommended the Mpumalanga Health Department produce an annual report on the number of healthcare workers per category in each district, which should include the number of people and size of areas covered by these staff, year-on-year with comparisons (from at least 2021), the vacancies, and the cost of these posts to the government.
Malamule said they had produced lists of filled vacancies, funded, and vacant posts.
Ritshidze’s project officer, Ndivuwho Rambau, said there are ongoing consultations with the provincial Health Department but this year they failed to meet the new HoD Dr Khetani Lucas Ndhlovu and the Health MEC because they were busy with plans to present the budget speech at the provincial legislature.
The DA’s head of research in the province, Ashleigh Trichardt, said the department does not have a concrete plan to deal with staff shortages as they are affected by litigation orders and costs, meaning there is less money for operational costs.
Mpumalanga’s Health MEC, Sasekani Manzini, in her budget speech tabled earlier this month, said the department would appoint 65 additional pharmacist assistants in primary healthcare facilities. Appointments will be done in the first quarter of the 2023/24 financial year with a budget of R19m, she said.
Poor infrastructure and clinic conditions
Ritshidze found that 79% of the facilities monitored required additional space while 26% of their toilets had no toilet paper or soap, and recommends the department audits all facilities to assess infrastructural challenges. Thereafter, it should develop a plan to renovate buildings and ensure adequate space for efficient and safe services.
Also flagged were the “inappropriate storage waste in most establishments, pest control (that is) not done in most of them, and lack of back-up water and electrical supply in most of them”.
Only 56% of facilities had a working generator and in some instances, the fuel had run out.
Malamule said tall facilities have generators and R83m has been allocated in this financial year to maintain supply.
The department had also appointed the Council for Scientific and Industrial Research (CSIR) to assess all facilities across the province and provide cost estimates for backlog maintenance and replacement of facilities. “We are also appointing plumbers to establish our maintenance hub for day-to-day maintenance,” he said, but gave no timeframes,
Health MEC Manzini had said seven new clinics were to be built, while one facility would be upgraded and expanded to accommodate more services.
“The department has set aside 11% (R 206 409 000) of the total infrastructure allocation for maintenance of health facilities to ensure they are accredited to the Ideal Facility programme,” she said. “
Also prioritised was “a preventative routine maintenance servicing and repairs of life-saving equipment programme and that maintenance is done as per manufacturer requirements”. An amount of R138m has allocated for this. Another 59 community health centres and 22 clinics will be prioritised in a budget allocation of R83.5m for diesel to mitigate load shedding.
Poor staff attitudes
Ritshidze found privacy violations and poor staff attitudes were ongoing, with 49% of gay, bisexual and men sleeping with men (GBMSM), 54% of drug-users, 37% of sex workers, and 34% of transgender people saying privacy was not well respected at clinics.
Malamule told Spotlight the department was continuing sensitisation training and ensuring that Batho Pele principles (government service standards) are adhered to. This was an undertaking since the first Ritshidze report.
And on anti-retroviral therapy, Ritshidze data showed ART refills were increasing, with most people with HIV (64%) now receiving three to six months’ supply at a time.
Mpumalanga scored best on this indicator out of all provinces. However, their numbers are low compared with 21 other countries, where 80% of people with HIV received three to six-month ART refills between October and December 2021
See more from MedicalBrief archives:
Report uncovers discrimination by Mpumalanga clinic staff
Survey confirms difficulties of SA’s key populations in accessing healthcare
Possible to provide good quality public sector care to the MSM group