A district in despair

The snapshot of the state of health in the Gert Sibande district is not a pretty picture.

The Treatment Action Campaign (TAC) has honed in on the Gert Sibande district in Mpumalanga as one of the hotspots for immediate intervention and support. Not only because it has been chosen as pilot sites for National Health Insurance, but also because health indicators show that there are serious health challenges. Mpumalanga is the province with the second highest HIV prevalence rate in the country, after KwaZulu-Natal. Gert Sibande, which is home to just over a million people, was last year named by the Minister of Health as the district with the highest prevalence of HIV among women in the country, at 46%. This means that almost one in every two women tested at antenatal government clinics is HIV-positive. Health minister Dr Aaron Motsoaledi has warned in the past that this figure is rising. Exacerbating this prevalence, Health-e News Service’s district profile for Gert Sibande reveals almost all of the people in Gert Sibande (up to 86%) are reliant on the public healthcare service.

Last year the South African National AIDS Council and government partnered to hold the main World Aids Day event in Piet Retief, which is in Gert Sibande. The TAC led a 2000-strong protest action to highlight the health crisis in the province and a memorandum was presented to government and more specifically the then Premier of the province who is supposed to chair the Provincial AIDS Council. Issues of concern raised in the TAC memo ranged from the lack of access to clean drinking water, to the non-functioning of AIDS Councils, to unfilled vacancies in already stressed and deteriorating hospitals and clinics, to ambulance services that are dismally inadequate.

Days later a follow up meeting took place between the Premier, Health MEC and the TAC where the officials gave an undertaking to follow-up and report back on the listed concerns by early February 2014. However, nearly six months later there has been no response from the Premier.

TAC activists and health workers continue to report on huge problems in the district and the NSP Review spent time in the province trying to capture some of the daily challenges faced by Gert Sibande residents.

Much of what is wrong in Gert Sibande is illustrated in a community survey report by consultancy group Health & Development Africa (HAD) done in 2010. It’s a report that highlights the key drivers pushing up the HIV prevalence rate in the district. These include high migrancy, low education levels, high unemployment, low socio-economic statuses for the majority of the population, high number of multipartner relationships, intergenerational sex, alcohol abuse and irresponsible sexual behavior, limited information about the prevention of mother-to-child transmission, and limited information about aspects of ARV and TB treatment. There is also a highly mobile trucking community that passes through the district that has fueled the explosion of the sex work industry as an important economic lifeline, putting sex workers in the category of high-risk sexual behavior, in order to make ends meet.

The NSP Review report reveals clear administrative failings throughout the province. They begin with facilities that stand as white elephants with equipment and consulting rooms that are hardly ever touched, or clinics built but never used. Where healthcare premises are in use, there are clinics and hospitals with inadequate facilities, in some cases unhygienic, undignified and unsafe. At these facilities patients are forced to wait outdoors for basic healthcare services, where they seldom get to see a doctor. They’re exposed to the elements for long hours every time they have an appointment and have little confidentiality or access to the care they need. Medical staff throughout the province are at best hamstrung to do their jobs better or at worst unmotivated about their jobs and simply go through the perfunctorily motions instead of offering actual healthcare. Across the board, staff shortages are widespread and the Department of Health is unable to attract medical staff to the province to fill critical vacancies. The memorandum listing the challenges is printed on pages 48 and 49.

High poverty levels force people to live in informal settlements that are mainly dotted around heavy industrial zones where air quality and general infrastructure of piped water, electricity and reliable transport are limited. Those in low-income households eat nutritionally comprised diets, and they often survive on one social grant for an entire family. In many households grannies are left to raise grandchildren. In some areas, the only water supply available can’t be trusted, but there are no alternatives.

Low education levels in the district mean many people are not able to access information or to extract the most useful information from sources that are available to them. And even with information, many people still need the guidance of others to help them navigate bureaucracies, paperwork and endless queues.

The TAC believes that the rising incidence of defaulting on ARV treatment also comes down to people not understanding the consequences of their choices. It shows up a gap in awareness programmes and counseling efforts. People are receiving medication but not taking them as prescribed because they don’t feel ill during the early stages of the disease.

Statistics aside, the real issues of health are found in the words and the stories of the people on the ground. These are stories that show just how complex the issue of health is in the province, and just how few opportunities there are for disempowered people to change their circumstances and how authorities are letting the poorest of the poor people down.

The TAC recognises there is much work to be done and more collaboration and shared responsibility that must prevail. There is no one failing. Rather multiple collapses from all quarters, impacting on a centre that clearly will not hold for much longer.

The NSP Review believes there are a number of steps that need to take place to remedy the situation:

• The South African National AIDS Council (SANAC) must come up with a plan for Gert Sibande district that tackles
  the identified drivers of high HIV prevalence.
• Timeframes must be established to cut the antenatal prevalence in the district.
• Political pressure must be exerted by SANAC and other role players for the district health services to be functional;
• There must ongoing and close monitoring of the district against a set of indicators.