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

Long clinic waits and too few get longer ARV refills in North West, says Ritshidze report
Takudzwa Pongweni
By Takudzwa Pongweni
11 Jul 2024
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The fourth edition of the Ritshidze North West State of Health report highlights prolonged waiting times, chronic staff shortages and persistent medication stockouts.

Long waiting times, too few clinic staff in place to meet the needs of public healthcare users and shortages or stockouts of different medicines, contraceptives and vaccines. These are some of the issues highlighted in the fourth edition of Ritshidze’s annual North West State of Health report. 

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

The report is part of a clinic monitoring project designed to improve the quality of healthcare services in the public sector. It was presented to the North West Health Department at a community meeting in Mahikeng on Thursday, 11 July.

Data in the report was collected between April and May at 72 healthcare facilities in the province (25 in the Bojanala Platinum District, 28 in Dr Kenneth Kaunda, and 19 in Ngaka Modiri Molema). Additional data was collected through interviews with 1,579 members of key populations in the community. 

Long waiting times


Waiting all day at the clinic remains an exhausting and frustrating reality for people in North West. 

“This is a major source of dissatisfaction… 75% of public healthcare users interviewed complained about long waiting times,” read the report.

While waiting times have decreased — down to an average of 3.4 hours after the facility opens — the average waiting time remains over three hours at 53 facilities monitored; over four hours at 32 and over five hours at eight.

The report quotes an individual living with HIV about their experience with Jericho Clinic in Bojanala. 

The person said: “I use Jericho Clinic. I have been using this clinic for a while and I am on HIV treatment. When I started to use the clinic I would come as early as 5am. I would only get assisted around 2pm. They do not treat patients well.”

Long waiting times are exacerbated by a staffing crisis, with 69% attributing delays to staff shortages. In 88% of facilities, insufficient clinic staff were reported, with 35% citing unfilled vacancies and 30% noting inadequate staffing levels. Additionally, 37% attributed delays to staff not working or working slowly.

A possible solution to reduce waiting times is to give people longer supplies of antiretrovirals (ARVs). 

“That way they will come back to the clinic less often. This is recommended in national ART [antiretroviral therapy] guidelines; however, implementation is deeply varied across districts. While 97% of people living with HIV interviewed in Bojanala reported getting a three-month supply of ARVs, only 37% of people in Dr Kenneth Kaunda did,” read the report. 

Another strategy to reduce waiting times is to allow people living with HIV to collect their treatment at pick-up points or adherence clubs, either at the facility or in the community.

“However, 33% of people living with HIV said they had never even been offered one of these options — and 51% still wish they could collect their ARVs closer to home,” read the report.

Of those using facility pick-up points, 51% said they must still collect files, take vitals, and see a clinician before getting their parcel — making clinic visits drag on longer than they need to. 

“National ART guidelines emphasise that a facility pick-up point should be an ART refill-only collection, in under 30 minutes. There should be no requirement to go anywhere, except to collect your pills,” read the report.

Read More in Daily Maverick: New North West health MEC Sello Lehari lacks health experience but vows to prioritise NHI

Staff shortage and attitude concerns


The shortage of healthcare workers at clinics remains a crisis.

Out of 3,364 public healthcare users, only 15% said there was always enough staff to meet the needs of public healthcare users. There are 351 vacancies unfilled across 30 facilities, and only 13% of managers said their facilities had enough staff. 

Of facilities reporting shortages, 35% blamed one or more unfilled vacancies, 30% said there were not enough positions, 24% said one or more staff members were away on sick leave, and 15% pointed to one or more staff members being away on study leave or at training.

“According to facility managers, the most commonly understaffed cadres were professional nurses, pharmacist assistants, enrolled nurse assistants, enrolled nurses, lay counsellors and cleaners. The most common vacancies reported by facilities were by far among professional nurses, followed by enrolled nurse assistants,” read the report. 

The report notes that a gap remains in North West between the staffing needed to ensure high-quality services and the staff present each day on site.

A public healthcare user is quoted in the report saying: “You will leave late around 2pm starving. My problem is that they don’t attend to us on time... I always tell them that I am not coming back to the clinic because we spend too much time. They said they have staff shortages. If someone is giving birth, they all go there and no one is left in the consulting rooms. When they go to the maternity room, they don’t let us know that they have an emergency.”

Furthermore, only 42% of people interviewed thought that staff were always friendly, while 58% said staff were welcoming.

Challenges in ARV dispensing


The report notes that the revised 2023 ART guidelines agree that time constraints represent a challenge to many people living with HIV in collecting treatment, and that efforts should be made to support eligible people living with HIV to get longer ARV refills (multimonth dispensing) and/or enrolment in pick-up points or adherence clubs (repeat prescription collection strategies). 

“​​Across the province, Ritshidze data shows that 71% of people reported getting a 3-6 month supply of ARVs in this reporting period. Yet, this varies widely across districts – 97% of people living with HIV interviewed in Bojanala reported getting a 3-month supply. However, only 37% of people in Dr Kenneth Kaunda reported getting a 3-month supply,” read the report. 

Most people are using pick-up points. 

“Of those interviewed by Ritshidze, this included 53% collecting at a facility pick-up point and 21% collecting at an external pick-up point. However, 23% of people still report collecting through standard medicine dispensing, having to consult with a clinician at the facility to get rescripted on each visit. Only 2% were using an adherence club,” read the report.

Stockouts plague the province 


This year there were 148 reports of shortages or stockouts of different medicines, contraceptives, vaccines and dry stock across 63 facilities.  

While fewer reports than in previous years, there remains some way to go to improve stock management and ensure people are not sent home empty-handed without the medicines they need, according to the report.

“The majority of stockouts and/or shortages were resolved in a month or less. Worryingly, however, 20 facilities reported stockouts of 1 month to 3 months, and 6 facilities reported stockouts of 3 to 6 months.”

The stockouts and/or shortages that were reported included: 10 analgesic medicines, 17 cardiac medicines, 16 contraceptives, 32 dry stocks, 19 HIV medicines, 16 lubricants, 7 maternal health medicines, 7 PrEP, 4 psychiatric medicines, 7 TB medicines and 13 vaccines. 

A public healthcare user spoke of their experience at Unit 9 Clinic in Ngaka Modiri Molema: “The nurse told me they don’t have my medication and I should go buy it. I am unemployed.” 

While protocol requires pharmacists or professional nurses to manage stock (receiving orders, updating the stock visibility system), the report found that in some sites, enrolled nurses, enrolled nurse assistants, facility managers and even cleaners assumed these responsibilities.

“This year only 9% of facilities had a pharmacist and only 18% had a pharmacist assistant — adding to the workload of already overburdened nurses in sites without,” read the report.

There were 32 reports of resolving stockouts by borrowing stock from another facility and 79% of facilities reported having a borrowing protocol. 

“Borrowing protocols where facilities borrow stock from each other when facing a shortage or stockout, only exacerbate stock challenges. When their order arrives, they will have to return what they borrowed. This creates a cycle of shortages occurring more quickly, leading to more total stockouts, and then facilities borrow again,” read the report. 

The way forward


The report includes priority recommendations, including some that were included in the first, second and third editions of the State of Health report, but have not yet been implemented.

Ritshidze requested a written response on each of the recommendations by the North West Department of Health and the Aurum Institute by 16 August 2024. 

The report notes that these failings in the health system contribute to slow progress in getting people to start and stay on HIV treatment, and calls for urgent action and reform. DM

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