OPINION: Community-Led Monitoring Dashboard Reveals the Crisis in SA’s ClinicsRitshidze is a system of community-led monitoring that has been developed by people living with HIV and activists to hold the South African government and aid agencies accountable and together improve HIV and TB service delivery. PHOTO: Rian Horn

OPINION: Community-Led Monitoring Dashboard Reveals the Crisis in SA’s Clinics

Comment & Analysis

Data collected by the Ritshidze community-led healthcare monitoring project is now being shared through a new, publicly accessible online dashboard. Authors involved with the project explain the kinds of insights this rich new data source can give on healthcare services in South Africa.

Ritshidze is a system of community-led monitoring  that has been developed by people living with HIV and activists to hold the South African government and aid agencies accountable and together improve HIV and TB service delivery.

Initiated in 2019, Ritshidze activists are implementing a model of detailed monitoring at over 400 public health facilities across eight provinces and 29 districts in the country on a quarterly basis. These 400 primary health facilities are responsible for delivering HIV services to over half of all people currently on HIV treatment in South Africa. Through observations as well as interviews with healthcare users, facility managers, and pharmacists every quarter, Ritshidze is monitoring over 140 indicators of the quality of the healthcare system.

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Unlike most healthcare system assessments funded by government and aid agencies that focus on the number of services being provided and tracking — in broad terms — patient outcomes, Ritshidze’s monitoring systems have been developed specifically to capture the persistent and intractable problems of the quality of healthcare service delivery in the country. These data can then hold duty bearers responsible for implementing fixes and corrections to improve service quality.

Indicators include stockouts and medicine supplies, compliance with TB infection control standards, human rights and privacy of patients, long waiting times, inadequate human resources, staff attitudes, and decaying and insufficient clinic infrastructure.

SA lagging on key indicators

For example, last April during the first wave of COVID-19 in South Africa, the National Department of Health issued a strategy document to reduce the risk of COVID-19 to people with HIV and TB. There were five priority interventions which included “[a]ccelerat[ing] decanting to external pick up points (PUPs)” and “[i]mplement[ing] multi-month dispensing for all chronic patients”.

Ritshidze data show that neither of these priorities has substantially improved since the department released this document. The data show that between October 2020 and June 2021 — of the nearly 18 000 patients Ritshidze has interviewed at these 400 facilities, 61% are still collecting their ARVs through standard facility dispensing in these clinics and less than 1% of people living with HIV have been provided with 6-month dispensing of ARVs. The majority of people living with HIV are still reporting having to collect ARVs every 2 months (61%).

This week, at the 11th IAS Conference on HIV Science, PEPFAR (The United States President’s Emergency Plan for AIDS Relief) presented data highlighting how South Africa is substantially lagging behind other countries in this regard. Across the 50 other countries where PEPFAR supports HIV treatment programmes, by June of 2020, 16% of people living with HIV were already receiving 6-month dispensing of ARVs and 53% were receiving between 3 and 5 months. Over a year after other countries have reached these levels of multi-month dispensing, only 23% of people in South Africa get 3-months of ARVs or more. In their 2021 guidelines, the World Health Organization (WHO) strongly recommends that people established on antiretroviral therapy be offered treatment refills lasting 3-6 months, preferably 6 months.

This is a bar chart. It shows the length of HIV medicine refills people living with HIV are given across the country. Out of 18 013 responses, 38 said they  received 1 week, 126 said they  received 2 weeks, 96 said they received 3 weeks, 2 592 said they received 1 month, 10 980 said they received 2 months, 3 922 said they received 3 months and 243 said they received 6 months.

This chart shows the length of HIV medicine refills people living with HIV are given across the country. Out of 18 013 responses, 38 said they received 1 week, 126 said they received 2 weeks, 96 said they received 3 weeks, 2 592 said they received 1 month, 10 980 said they received 2 months, 3 922 said they received 3 months and 243 said they received 6 months.

This is unacceptable and made even worse in the time of COVID-19 where it is established that people living with HIV are at increased risk of hospitalisation and death from COVID-19. Failing to implement these policies exacerbates the vulnerability of people living with HIV to COVID-19 by exposing them to clinic conditions more often than necessary.

Unique to the Ritshidze project is the ability to drill into these issues on where — which provinces, districts, and clinics — require intervention. While no province is doing well, there are significant geographical differences. Limpopo, Eastern Cape, and Free State are all — on average — dispensing less than two months of ARVs to people living with HIV, with many individuals still collecting monthly refills. Mpumalanga and Gauteng are — by contrast — performing better with people living with HIV getting more than 2 months on average.

Alt text: This table shows the length of HIV medicine refills across provinces, with Mpumalanga and Gauteng scoring best, followed by KwaZulu-Natal and the North West scoring in the middle range, and Eastern Cape, Free State and Limpopo scoring worst. You can access an accessible version of this table here

This table shows the length of HIV medicine refills across provinces, with Mpumalanga and Gauteng scoring best, followed by KwaZulu-Natal and the North West scoring in the middle range, and Eastern Cape, Free State and Limpopo scoring worst. You can access an accessible version of this table here.

Only half of the districts monitored by Ritshidze show more people living with HIV receiving 3-month refill lengths than 1-month, with districts like Nelson Mandela Bay (EC), Ehlanzeni (MP), and King Cetshwayo (KZN) leading the way, while districts like Capricorn (LP), Mopani (LP), and Lejweleputswa (FS) are dispensing far more 1-month supplies than 3-month. Facility level data show which specific facilities are failing to implement and dispense medicines appropriately as well, with 18 facilities dispensing more 1-month supplies of ARVs than either 2 or 3-month supplies combined. Data such as these tell us not only what is failing, but where efforts must be focused to resolve these problems.

New public dashboard

While Ritshidze harnesses this data for advocacy and feedback to facilities, it is critical that the community of South Africa, health journalists, policy-makers, and all duty-bearers have access to them to also assess the health system. This is why Ritshidze is making our data publicly accessible online at http://data.ritshidze.org.za.

The dashboard — developed by amfAR — provides an easy-to-use interface for all stakeholders to access, download, and analyse our data.

One note, while Ritshidze does monitor several facilities in the Western Cape, the Western Cape Department of Health has not yet given full permission to monitor and release any data on the Western Cape publicly. We are still in discussions with the Western Cape Department of Health and hope that this issue will be resolved soon.

*Rambau is a Ritshidze Project Officer, Tshabalala is National Chairperson of the Treatment Action Campaign (TAC), and Honermann is the Deputy Director of Public Policy at amfAR. You can follow Ritshidze on twitter, facebook and instagram for regular updates or go toritshidze.org.za for more information.

NOTE: The TAC is a member of the Ritshidze  project and one of the authors of this op-ed is a TAC leader. Spotlight is published by SECTION27 and the TAC, but is editorially independent, an independence that the editors guard jealously. The views expressed in this opinion piece are not necessarily shared by Spotlight.