In-depth: A tale of two make-do clinics in the rural Eastern Cape

In-depth: A tale of two make-do clinics in the rural Eastern CapeThe Macacuma Clinic that operates in an old school building is one of the clinics servicing the people of Sterkspruit in the Eastern Cape. PHOTO: Black Star/Spotlight
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In 2007 during a two-day imbizo in the Eastern Cape, then-President Thabo Mbeki told the community of Ugie and surrounds in the Joe Gqabi District, “to not wait for the government to help them but start initiatives that will draw the government’s attention”.

Now, 16 years and three presidents later, the community of Ugie still has to make do with a residential four-roomed house that was repurposed as a clinic. While elsewhere in rural villages in Sterkspruit, in the same district, residents desperate for healthcare services, years ago in 1998 took it upon themselves to convert part of an abandoned school building into a health facility they called Macacuma Clinic (sometimes called the Macacume Clinic).

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But this year, Ugie residents, at least, received some good news.

During her budget speech in March, Eastern Cape Health MEC Nomakhosazana Meth acknowledged that the maintenance of facilities is an important aspect of ensuring that the department is ready for the full implementation of South Africa’s proposed National Health Insurance (NHI) system.

Meth said that the provincial health department’s focus will be on the maintenance and upgrading of existing buildings in the 2023/24 financial year and over the medium-term expenditure framework (MTEF). She said the department has allocated a budget of over R4 billion for this and the Joe Gqabi District has received a share of more than R1 million allocated for maintenance. You can see the full list of planned infrastructure projects here.

An entrance at the Ugie Clinic in the Eastern Cape. PHOTO: Black Star/Spotlight

Ugie Clinic will be one of the five facilities to be renovated and upgraded in the Elundini sub-district in Joe Gqabi over the 2023/24 MTEF (which covers three financial years). The Macacuma Clinic in the Senqu sub-district, however, is not included in these plans.

Member of the provincial legislature for the United Democratic Movement, Nkosinathi Ndlodaka tells Spotlight he doesn’t understand why it took so long.

“Thabo Mbeki spoke on behalf of the government when he promised a clinic to the people of Ugie. It was not going to be built with his own money. Considering that the current administration is still in power, I don’t know why it has taken 17 years for them to realise that a promise was made,” he says.

Ndlodaka called on the department to “avoid wasting money on temporary solutions”. He did, however, say that they need new toilets at Ugie Clinic. “And the department’s failure to have a proper waste storage facility at Ugie Clinic could have legal implications and that must be attended to as a matter of urgency.”

Making do despite challenges

For now, people in Ugie who depend on public healthcare services still have to make do with a four-room clinic. During Spotlight’s visit, the waiting area at the clinic was shared by patients and a data capturer. The facility manager’s office doubles as a consultation room and a storage area for patient files.

“Not only does our facility create inconveniences but it also inconveniences patients, since the two rooms we used for consultations are about five meters wide and no privacy is available. Any person inside the building can easily listen to patients being consulted,” a nurse tells Spotlight. She asked not to be named for fear of repercussions from the provincial health department.

Woman walking on a dirt road carrying a bag and a baby on her back
Accessing healthcare services is a struggle for some communities in Sterkspruit in the Eastern Cape as they have to travel long distances to access these services. PHOTO: Black Star/Spotlight

“I have been told that then-President Thabo Mbeki during his visit to Aliwal North and Ugie in 2007 as part of the Presidential Imbizo programme suggested that a new Community Health Centre needed to be built, but that never happened,” she says.

“Despite another promise in 2022 that our clinic will be constructed in February 2023 – they even cleared an open space next to our clinic – but nothing has happened. It is not a surprise to us that February came and went without our clinic being built,” the nurse says.

The Ugie Clinic waiting area is shared by patients and a data capturer. PHOTO: Black Star/Spotlight

She also says while they understand that building a clinic is a big project, it would help if the department at least fixed the toilets first. “If they are struggling to fix a toilet, how do you think they will be able to build a clinic?”

She says they only have one toilet that staff share with both male and female patients.

Poor infrastructure and staff shortages

Elsewhere, in the same district, residents of Macacuma village near Sterkspruit depend on a clinic that is run from an abandoned school. Following a merger between Egugwini Junior Primary School and Macacume Senior Primary School, the old school building was left abandoned, and residents felt that leaving a building to rot was a waste of taxpayers’ money. They repurposed part of the school into a satellite clinic around 1998 but have since battled chronic staff shortages and infrastructure challenges.

The school has two block buildings with three classrooms used for the clinic. The other rooms are being used by community members for a victim empowerment centre, a community centre, and an old age centre.

Patients waiting outside an old, abandoned school building that was repurposed by community members in Sterkspruit as a satellite clinic around 1998. PHOTO: Black Star/Spotlight

The state of the Macacuma Clinic came under the spotlight during the provincial legislature’s health committee visit from 10 to 14 October last year, when they visited several public health facilities in the Joe Gqabi District. They visited Ugie Clinic, among others. The committee’s findings, observations, and recommendations were captured in a report. In February, as part of the “Taking the Legislature to the People” programme, the committee presented the findings to the community.

Presenting the findings, committee chairperson Nozibele Nyalambisa painted a bleak picture of poor infrastructure and staff shortages.

The committee report, among others, noted that the infrastructure at most of the facilities – clinics and hospitals in the district – is dilapidated and therefore “poses a health hazard to both staff and patients”, which in turn will lead to litigation, the report warns.

The report notes that clinics are still subject to space challenges, which include unreliable water supply and dilapidated structures and many also do not have proper fencing. It also notes that there is a “serious challenge of stipends” which are not paid to Clinic Committees and Hospital Board Members. This, the committee said, is “unacceptable and tantamount to unfair labour practice for a person to work without being remunerated and therefore they should be paid what is due to them”.

Patients queuing at the Macacuma Clinic in Sterkspruit in the Eastern Cape. PHOTO: Black Star/Spotlight

According to the report, the department has a tendency to defer replacement when an official has resigned, died or retired whilst posts are funded. The report also noted that out of 21 clinics in the Sub-District only seven have permanent operational managers. It was also found that at some clinics there were no visiting doctor and that at nine clinics, the contracts with pharmacy assistants came to an end in March this year and those clinics would be left without anyone to dispense medicines.

At Ugie Clinic, the report states, space constraints also meant that “medical waste is kept next to the toilet due to unavailability of store room”.

Spotlight asked Nyalambisa what steps are being taken by the committee to make sure its recommendations are implemented, but we did not get a response after several follow-ups. Spotlight also asked the provincial health department about how decisions around the upgrading of clinics are made and how the department intends to address the staffing issues. We did not receive responses to these questions despite asking the department several times.

A community’s hopes

Meanwhile, Nerman Gaga (71) of the Macacuma Clinic Committee, says their village had never had a proper healthcare facility since people settled there in the early 1900s.

“Our hopes are pinned on the recent visit by government officials [the health committee members] to take the challenges of the facility to the department to reach a lasting solution. At our last meeting with the sub-district management, we were informed that the school did not meet the standards for it to be used as a clinic, so the department cannot refurbish it. Besides the fact that we do not have a proper building, we also lack running water and we only harvest rainwater. When there is no water, we must fetch water in buckets to use at the clinic and patients are expected to bring their own water,” Gaga says.

“The residents of Macacuma used to [before repurposing the school] attend Zanethemba Clinic in Thaba-Lesoba Village, but they were having difficulties getting to Zanethemba due to lack of transport,” says a facility worker who asked not to be named. “To reach the nearest hospital, Mpilisweni Hospital, the sick had to travel over 20 kilometres. To alleviate this situation, villagers and the department renovated an abandoned Egugwini school building and turned it into a clinic. The clinic began as a satellite clinic of Zanethemba Clinic and all the staff were borrowed from different facilities in the district.”

The old school building that houses the Macacuma Clinic is also being used by community members for a victim empowerment center, a community center and an old age center. PHOTO: Black Star/Spotlight

The worker says there is now only one professional nurse and an assistant nurse who were employed when the clinic became a full-service clinic around 2013. There are four community health workers and two home-based care workers. “That single nurse is under massive strain, as she has to treat [about] 1 500 patients per month. To add insult to injury, the only assistant pharmacist was taken away in March to another facility that is bigger than ours. In addition to the nurse being a manager, she is now also a pharmacist at the same time,” the worker says.

According to another healthcare worker at the clinic, patients feel the impact of staff shortages. “When this single nurse is on leave, the department borrows another nurse from another facility so that the patients can receive medical care. When we contacted the department about the shortage of staff, we are told that there is no budget to pay for new staff and that the Macacuma matter would be addressed after the building issue has been resolved. Having no budget and no general assistants, we have resorted to cleaning the facility on our own while using our own cleaning materials, since the department does not provide us with any.”

The worker says there are three villages in Senqu local municipality served by the clinic and calling an ambulance “is of no use since it takes hours to arrive or never arrives at all”. These three converted classrooms are in a state of disarray, which makes our facility unusable. Our patients are mainly the elderly, who have difficulty accessing these classrooms, but since we don’t have another alternative, we use them.”

Older man, Nerman Gaga standing next to a sign for the Macacume Clinic
Nerman Gaga, of the Macacuma Clinic Committee, says their village never had a health facility since people settled there in the early 1900s. PHOTO: Black Star/Spotlight

Notwithstanding these challenges, villagers say the clinic has become an integral part of their lives since it is easily accessible.

“The clinic is our hope,” Thandiswa Msala (35) tells Spotlight, “since residents used to spend R80 traveling to the nearby Zanethemba Clinic, and it was always full since it served more than four villages.”

“My grandfather used to go to Zanethemba Clinic early in the morning and sometimes he would return empty-handed without his chronic medication. It was far away for those who could not afford bus fare, and along the way there was an open space where criminals may target them,” Msala adds.

One of the healthcare users at the Macacuma clinic, Winky Mguye, says, “despite the clinic’s small size, it is well-managed and clean and the queue moves quickly. Approximately two hours are spent waiting between arrival and departure at various points. The only challenge we face is space, since we cannot wait inside due to insufficient space.”