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Clinic staff shortages and wait times frustrate access to healthcare in Free State

Clinic staff shortages and wait times frustrate access to healthcare in Free State
Takudzwa Pongweni
By Takudzwa Pongweni
27 Aug 2024
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Ritshidze’s annual report on access to healthcare at Free State clinics reveals critical systemic issues, including long wait times, unprofessional staff and poor facility conditions.

Diagnosed with diabetes and HIV three years ago, Solly now endures monthly visits to the Nthabiseng Clinic in Masaleng Village near Witsieshoek, where he spends hours in frustrating queues and faces unprofessional behaviour from some staff members. Arriving at the clinic before dawn to secure a place in line, he frequently waits until early afternoon for his turn.

“I come to the clinic sometimes at 6am to wait for it to open at 8am and I will only get out there again after maybe midday,” said Solly, who was quoted in Ritshidze’s fourth report on the state of the Free State health system and whose name was changed to protect his identity. 

People are forced to endure the long wait even before the clinic opens as they’re afraid they’ll be turned away if they are at the back of the queue. Solly’s frustration is compounded by the deplorable state of the clinic’s sanitation facilities and a lack of accountability among staff who allegedly prioritise personal connections over patient care.

“There is one nurse there who is a problem because she will push her friends, or some people that she knows, to the front of the queue, and we others must wait for even longer,” said Solly.

The appalling state of the clinic’s bathrooms also upset Solly: “You can’t use the toilets because they are dirty and sometimes there’s no water. It’s very bad when you see the old people going outside to the yard to go to the toilet, but the toilets don’t get fixed. It’s not just the toilets… sometimes you can’t even wash your hands.”

Solly’s story is a common one in the Free State and his experience at Nthabiseng Clinic is a stark example of the struggles faced by many in the public healthcare system, as highlighted in Ritshidze’s annual report.

The latest Ritshidze report highlights systemic issues across the Free State, revealing that only 17% of people with HIV receive a three-month supply of antiretroviral medication. Long wait times, a culture of unfriendliness and punishment from staff, denial of services, poor treatment literacy, lack of availability of lubricants and dirty facilities are some of the issues highlighted in the report.

Ritshidze is a community-led monitoring system developed by organisations representing people living with HIV, including the Treatment Action Campaign and the National Association of People Living with HIV.

The report is part of a clinic monitoring project designed to improve the quality of healthcare services in the public sector. It was presented in a district community meeting in Thabo Mofutsanyana on 27 August 2024.

Data in the report was collected between April 2024 and May 2024 and interviews took place with 2,659 public healthcare users.

Long wait times and staffing issues


Long waiting times continue to frustrate public healthcare users who waste hours in queues waiting for check-ups or even just to collect medication, with 81% of users saying the waiting times at facilities are excessive.

The average waiting time was more than three hours at 46 facilities monitored, more than four hours at 34 of those, more than five hours at 15 of those, and more than six hours at five others.

“This is a very long time to spend at a facility in which people are usually only seen for a very short consultation – and this is a major source of dissatisfaction for those who experience long waits.

“For people living with HIV either collecting refills through standard dispensing or at facility pick-up points, or returning to the facility for a rescript, spending an extended time at a facility increases the risk of that person interrupting treatment and/or disengaging from care,” read the report.

The shortage of healthcare workers at South African clinics remains a problem and the knock-on effect leads to long waiting times. Of 2,657 public healthcare users interviewed, only 24% said there was always enough staff to meet their needs.

A transgender individual from Lejweleputswa is quoted in the report: “Staff shortages are still the biggest problem in the facility. If I arrive at the clinic between 8am and 9.30am, I normally leave the clinic without being attended to at 4pm when they are closing.” 

There are 143 vacancies across 23 facilities, with only 20% of the facilities’ managers saying their clinics have enough staff, according to the report. Delays are only exacerbated by chaotic paper filing systems, where staff struggle to locate people’s medical files or lose them altogether.

“Filing systems were observed to be in good condition in only 57% of sites monitored, mostly due to filing rooms being too small to maintain and/or filing systems being messy,” read the report.

Of 2,648 respondents, 22% said after registering it took 60-120 minutes to get their file, and 18% said it took more than 120 minutes to get their file.

A person living with HIV at Phuthaditjhaba Clinic is quoted in the report: “I defaulted because they couldn’t find my file when I went on my appointment date. They tell you to come back the following day and the next day they still can’t find it.”

Culture of unfriendliness


Ritshidze’s data reveals that only 50% of respondents thought that the staff were always friendly and 49% thought staff were only sometimes or never friendly. Additionally, only 47% felt comfortable/very comfortable in using the facility.

A person living with HIV at Phomolong Clinic said: “I can hear how they talk to other patients. I dread going to the clinic... When you ask questions they are rude. They always say we are abusing them, but they are the ones abusing us with their attitude and rudeness. We leave the clinic hurt because of their actions. Going to the clinic is very stressful. You can ask anyone from the community. They will tell you that you don’t get a wink of sleep the night before going there.”

Out of the 560 people living with HIV who had missed appointments, only 25% said that staff were welcoming when they came to collect antiretrovirals (ARVs) if they had previously missed a visit, which is a lower figure compared to the 54% from the 2023 report. Alarmingly, some people even report health workers denying them ARVs following a late or missed appointment. 

Read more: Free State bottom of the list when it comes to multi-month dispensing of ARVs, survey finds

“Twenty-six percent said staff shouted at them instead. Only 1% of people said that staff ask how they can make ARV collection easier; only 1% were offered a longer supply of ARVs to make collection easier, and 0% said staff told them about external pick-up points closer to home which would make collection easier,” reads the report.

This is despite the 2023 National ART Guidelines which recommend providing people living with HIV with longer refills and the option to enrol in pick-up points or clubs to simplify the collection of their treatment.

The report also notes that staff continue to mock, judge, or refuse to acknowledge people who use drugs, sex workers, and members of the LGBTQIA+ community – let alone be sensitive to or knowledgeable of the health services they need.

“The lack of understanding and support for transgender individuals at the clinic makes it impossible for me to feel safe or respected. Sometimes, despite being very ill, I am forced to leave the facility without getting the care I needed,” said a transgender man quoted in the report.

ARV refill issues


The 2023 ART Guidelines recognise that time constraints hinder many people living with HIV in collecting their treatment. They advocate for longer ARV refills (multi-month dispensing) and enrollment in pick-up points or adherence clubs, including for children and adolescents.

These strategies facilitate easier treatment access, improve adherence, and alleviate congestion and waiting times in the healthcare system. However, across the province, Ritshidze found that only 17% of people reported getting a 3-6 month supply of ARVs in the reporting period.

At the Phuthaditjhaba Clinic, a person living with HIV is quoted in the report: “They give me treatment for one month so I need to come to the clinic every month. When I ask for treatment for at least two or three months, she refuses and says I need to come to the clinic.”

The Free State has made the least progress towards giving people longer ARV refills out of all provinces monitored by Ritshidze. Only 11% reported receiving a three-month supply in Thabo Mofutsanyana and 25% in Lejweleputswa, compared with 98% of people reporting a 3-6 month supply in Mopani (Limpopo), and 97% in Bojanala (North West).

Read more: Long clinic waits and too few get longer ARV refills in North West, says Ritshidze report

The report continues to call for urgent action to improve health services across health facilities in the Free State, noting that the failures in the health system are core reasons why people struggle to stay on ARVs or access HIV prevention.

“Instead of feeling less anxious and more in control of your own health, clinic visits are frustrating and time-wasting. Instead, clinics must become safe spaces that provide empathy and support to everyone, regardless of who they are, what they do, or where they come from. Clinics must offer evidence-based strategies to make staying on treatment easier. This is critical to ending Aids,” read the report.

The Ritshidze report included a list of recommendations, which were submitted to the Free State government. Ritshidze asked the provincial government to respond by 30 September. DM

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