KZN’s HIV and TB plan: Good on structure, low on detail

The National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 is supposed to guide South Africa’s response to HIV and TB. While this national plan sets out broad targets and strategies, the implementation of this plan depends on provinces. To this end, each province had to develop a provincial NSP implementation plan (PIP). KwaZulu-Natal’s (KZN) PIP is called the Multi-Sectoral Response Plan for HIV, TB and STIs for KwaZulu- Natal Province 2017-2022 – but in this article we will refer to it just as the KZN PIP.

Broadly speaking, the KZN PIP’s engagement with the governance and consultative structures required to implement a plan like this is refreshingly realistic and shows an awareness of the very real risk that PIPs can become inconsequential processes parallel to existing government planning processes. The plan also does a good job of using data to define the particular problems in the province and flagging, in general terms, the kind of interventions that are required. Unfortunately, the KZN PIP is very low on detail when it comes to implementation – which is deeply disappointing in an implementation plan.

Some context

KZN is at the epicentre of South Africa’s HIV epidemic, if not the world’s. Annual AIDS deaths in the province peaked at 87 000 in 2005 and fell to around 17 000 in 2017. In 2019 there was probably around 15 000 deaths, although there is significant uncertainty regarding the 2019 figures. The decline in AIDS deaths in the province is driven largely by the provision of antiretroviral therapy – in 2005 there were 27 000 people on treatment in the province, today there is around 1.4 million.

One major concern however, is that growth of the HIV treatment programme in the province has slowed significantly in recent years. In 2014 around 230 000 people in the province were newly started on treatment. That number has dropped every year since and is now estimated to be under 100 000.

While AIDS deaths have declined dramatically, the rate of new HIV infections remains stubbornly high in the province. While the estimated 61 500 new infections in 2017 is much better than the 160 000 per year seen around the turn of the century, it is nevertheless high and means that the absolute number of people living with HIV keeps going up. Just over a third of the new infections in 2017 (around 21 000) were in women and girls aged 15 to 24. Around two million people in the province are living with HIV.

The KZN PIP

Probably the most important target in the KZN PIP is to reduce new HIV infections to below 20 000 by 2022 – roughly a third of 2017 levels. Modelling suggests that this very ambitious target will not be met and that by 2022 levels would still be in the high 40 000s. According to the PIP “interventions revolve around expanded and intensified provision of biomedical services, sexual and reproductive health and the provision of pre-exposure prophylaxis to high risk groups.”

While specific mention of PrEP is welcome, the PIP rather confusingly says that PrEP should be provided “as part of a prevention package for the general population and key population groups e.g. sex workers” and elsewhere it refers to providing PrEP to “high risk groups”. Who exactly should be offered PrEP is never made much clearer than this. The plan does not specifically set out to provide PrEP to women and girls aged 15 – 24, as one might expect given the high infection rate in this group. It also doesn’t set any concrete targets or make any meaningful commitments regarding PrEP.

Some might argue about the cost effectiveness of PrEP, but even if the cost-effectiveness case is not as strong as that for say medical male circumcision, one could argue that the state has an obligation to nevertheless provide young women and girls at very high risk of contracting HIV with the means to protect themselves. Either way, if ambitious PrEP targets were rejected based on cost-effectiveness grounds, then the PIP should state that explicitly.

Given the high rate of infection in young women and girls, one would also expect a strong focus on the promotion of safe sex and condom use. As is recognised in the PIP: “While the province achieved its condom distribution targets, these were not adequate when calculated at number of condoms per eligible male.” One would expect such an admission to result in ambitious new condom distribution targets. Maybe more importantly, given the high rates of HIV in young women and girls, one would expect an unequivocal commitment to making condoms available at schools. Yet, while the PIP does not prohibit it, it certainly does not make a strong case for increased condom distribution or making condoms available in schools.

DREAMS and various specific interventions are mentioned, but unfortunately the KZN PIP does not break any new ground in plotting how the province will address HIV infection in young women and girls.

Touches on key issues

Though lacking in detailed planning and concrete commitments, the KZN PIP does nevertheless touch on a lot of the key interventions required at this stage of South Africa’s response to HIV and TB and provides useful district by district breakdowns of some key indicators. It is to be welcomed, for example, that HIV self-testing and same day initiation are both endorsed. With some help and guidance from national or the province, these are issues that districts can run with.

While increased testing is relatively easy to do, many other interventions require the province to play a greater role and for districts to be given more guidance. The KZN PIP could, for example, have set targets for how many adherence clubs would be needed in each of the province’s districts and included an estimate of the additional human and financial resources that would entail. Without such guidance and support from a provincial level, many of the good things mentioned in the KZN PIP might not be implemented, or not be implemented with sufficient ambition. It could be that these issues will happen through other channels, but the PIP should at least contain some thinking on it if it is to meaningfully impact implementation.

The PIP identifies some serious problems in the province’s HIV response. For example, it states that “information indicated that only 55.7% of those on ART had viral loads done”. Identifying and admitting problems like this is positive. It is not clear however from the PIP what will be done to address this problem. Ideally, a serious problem like this would have triggered the commissioning of research to understand why viral load testing rates are so low – and that research would then have been used to inform the PIP.

Reduce TB incidence by 50%

The KZN PIP sets a target of reducing TB incidence by 50% by 2022 when compared to 2017 levels. According to the KZN PIP: “Currently TB incidence is way above the World Health Organisation threshold of 200 per 100 000 population. Earmarked interventions relate to increasing the uptake of TB preventive therapy using various strategies including mass screening.”

The PIPs endorsement of interventions like mass TB screening and intensify contact tracing is to be welcomed. But whereas the intent is good, the lack of actual planning here too is concerning. There is no sign in the KZN PIP of serious engagement with the human resource requirements of expanding screening and contact tracing – and without the people to expand these services the expansion simply won’t happen. We had similar concerns with the NSP at a national level. The explanation then was that this kind of grappling with the nitty gritty of implementation would be addressed in the PIPs.

It is true that the KZN PIP does include a matrix of which departments and sectors or organisations would be responsible for various interventions, but it does not go much further than this. The background is good, the general ideas are good, but in the final analysis there is no real plan to implement.

Serious about structure

Some of the short comings with the KZN PIP outlined above might be explained by the disconnect that often exists between AIDS council and Department of Health planning processes. An AIDS council might set laudable goals, but the Department of Health controls most of the relevant resources. For this reason, the NSP and PIPs should ideally be taken into account in departmental planning processes and budgets. The odd thing is that, unlike most provinces, KZN seems actually to have put some real effort into making these various processes talk to each other. In fact, much of the KZN PIP engages with just this kind of structural problem.

The PIP states: “This plan has to the extent possible incorporated issues relating to HIV, TB and STIs as mentioned in other departmental and sector plans to enhance mainstreaming and multi-sector participation. It further presents a platform for participation in the response by departments and sectors that may not have HIV, TB and STIs activities in their current plan. They should use this plan as a reference document to inform their implementation in line with the departmental mandate. The activities can then be incorporated into departmental strategic plans when the opportunity arises.” And, “The PCA through its secretariat will be required to facilitate the process of ensuring that all departmental plans support the goals and objectives of this plan.”

The above should be in every PIP – with a premier using his or her clout both as premier and head of the PCA to enforce it.

In KZN the Premier has for years been chairing the Provincial AIDS Council and Spotlight sources report that the council meets regularly and is functional. In addition to the PCA, the PIP indicates that the province has 11 District AIDS Councils and 43 Local AIDS Councils. It seems however that leadership at PCA level has not filtered down. The PIP itself states: “While functionality of the PCA was impressive, that of AIDS Councils at the other spheres of government was generally poor especially, at local municipality and ward level. In some cases ward AIDS Committees were non-existent. More broadly all AIDS councils face the challenge of effective stakeholder participation with few stakeholders from different departments, organisations and civil society participating in AIDS councils. This affects governance and mutual accountability of the response.”

The problem of ensuring greater functionality at district or local AIDS council level is certainly not unique to KZN. It is also not something that can be solved in a PIP. For it to be flagged and grappled with in a PIP is welcome.

According to the KZN PIP “6 districts and 21 local municipalities had AIDS coordinators that were exclusively assigned to HIV.” Ideally all districts will have such AIDS coordinators, and all district-level councils will be chaired by mayors.

The plan also shows a good understanding for the fact that health crises of the scale of HIV and TB cannot be stopped by the Department of Health alone. It reads: “Government organisations, non-government organisations, civil society, the private sector, development partners, traditional leadership and the religious sector all have individual and complementary roles in implementing this plan and ensuring delivery.” It is arguably at district and local level that these “individual and complementary roles” are most important. More guidance on how to turn these good intentions into actual shared programmes and shared responsibilities may be useful.

 

No costing and no communications strategy

 

One area that the PIP gives a lot of attention to is communications. It goes as far as to commit that a “comprehensive provincial multi-media HIV, TB and STIs communication strategy will be developed”. This strategy is mentioned time and time again in the PIP in different contexts and in relation to various specific interventions.

The idea of a single communications strategy around HIV and TB in the province is not a bad one. While some HIV communications projects in South Africa have had only limited success, that is not to say that a properly conceived and executed strategy might not be more successful in KZN.

Unfortunately, according to Bonolo Pududu of the HIV and AIDS Directorate in the office of the KZN Premier, by mid-2019 this communications strategy has not yet been developed.

Another concern is that by mid-2019 the KZN PIP, which is a 2017 – 2022 plan, has not been costed. According to Pududu, this is not the province’s responsibility. “The costing of the Provincial Implementation Plans (all provinces) is/was the responsibility of national (i.e. SANAC),” says Pududu. “Initial processes commenced to cost the plans, however, the finalisation of this process is yet to be communicated.”

The PIP refers to a monitoring and evaluation framework document. A draft of this framework was shared with Spotlight. According to Pududu, “final consultations” with “provincial stakeholders” have not yet taken place and the PCA has not yet adopted the framework.

The lack of a costing of the PIP, the fact that the communications strategy has not been developed, and the fact that the M&E framework is only now being adopted are all worrying signs.

Though the KZN PIP is low on detailed plans, there is also some indication that some of the good things in it are not being implemented. Under goal 4 “Social and structural drivers” the PIP sets out to “implement and scale up a package of harm reduction interventions for alcohol and substance use”. Yet, for much of 2018 a needle-exchange programme in Ethekwini was shut down by the authorities, ostensibly because needles were not being disposed of appropriately.

What is to be done

With a new Premier in the province and a new MEC for Health, there is significant potential for change in KZN. The various good things in the PIP can and should be built on.

Ensuring district and local AIDS councils meet and are given sufficient guidance is one urgent priority. Making this happen will require strong political leadership together with clear thinking on what roles district and local AIDS councils can and should play.

A second urgent priority would be to flesh out some of the ideas in the KZN PIP into fully fledged implementation plans. How should new infections in young women and girls be addressed? Should the province embark on a massive scaling up of PrEP for young women and girls? Should there be a new safe sex and condom distribution campaign? Will these campaigns be funded and who will implement them?

Thirdly, whatever revised plan is made must be costed and, if a communications strategy remains central to the plan, then such a plan must be developed. If the PCA and the Premier is serious about the KZN PIP, then they must show that seriousness by executing the plan and integrating it into government planning and service delivery in the province.

Note: The KZN PIP uses estimates from the Thembisa model version 3.2. In this article we use more recent estimates from Thembisa version 4.1.)

 

 

Gauteng and KwaZulu-Natal Circulars on migrants may be a sign of things to come

Opinion by Sasha Stevenson

The first few days of March 2019 must have been a time of great uncertainty for migrants in South Africa in need of health care services.

On 1 and 6 March, circulars from the Gauteng and KwaZulu-Natal Departments of Health respectively came to light. The Circulars said that all non-South Africans, other than refugees, would from now on have to pay in full for all health care services at public clinics and hospitals. Payment would be due upfront or on discharge. This was a huge change from the current legal position which assures everyone, regardless of citizenship or immigration status, free primary health care services and requires that refugees, asylum-seekers and undocumented migrants from SADC states be treated like South Africans when needing hospital care and means tested to determine their ability to pay. Pregnant and breastfeeding women and children under six are given special protection and assured free services in government facilities.

By 3 March the National Department of Health had said that it had withdrawn the national-level memo on which the Gauteng and KwaZulu-Natal Circulars were based. By the following day, Gauteng too withdrew its Circular. After various requests for clarity KwaZulu-Natal’s Acting Head of Health Dr Musa Gumede confirmed on Thursday night (7 March) that their circular had too been withdrawn (Five weeks after it had been sent).

So the question now is what this flurry of memos and circulars (and failure to clarify) says about what is happening in the National, KwaZulu-Natal and Gauteng Departments of Health. Over-eager junior officials have taken the blame for the distribution of the memo from the National Department but the Gauteng and KwaZulu-Natal Circulars are more or less in line with the approach to migrants in the NHI Bill. The sentiment didn’t come from nowhere.

The NHI Bill repeals the provision of the National Health Act that provides for free health services. It also cuts out entirely undocumented people from NHI and limits services available to refugees and asylum-seekers under NHI to emergency services, services for notifiable conditions of public health concern, and paediatric and maternal services at primary health care level. So if, as a refugee fleeing persecution in the DRC you need to give birth in a hospital or your child is seriously ill or you need ARVs, you will have to pay for them.

In this way, the NHI Bill, like the National memo and Gauteng and KwaZulu-Natal Circulars, envisage a step backwards in access to services for people who aren’t South African. This is the opposite of progressive realisation of rights – a constitutional imperative.

And so while the battle for now seems to have been won, the war is far from over. In a country with limited resources and a strained health system, there will always be pressure to cut spending. We cannot, however, do so in a way that violates constitutional rights.

Read the full SECTION27 statement here

* Sasha Stevenson is an attorney and the head of health at SECTION27

 

 

Funding by Faith

By Ufrieda Ho, Spotlight

Even for a woman of faith, breaking bad news is never an easy thing to do.

When Sister Krystyna Ciarcińska called a meeting for the 30 caregivers of the

Sporting their blue golf shirts are some of the Koinonia Orphans caregivers who have
changed the lives of at least 900 children in 13 villages in Uzimkhulu. From left are
Ntombovuyo Langa, Bongekile Dlamini and Gloria Tsezi. In front is Lodiwe Ndzimande.

Koinoina Orphans Project in rural Umzimkhulu, KwaZulu-Natal at the end of winter this year, she did so with a heavy heart.

“I was so sad and I didn’t know what I was going to say to them,” she says, remembering that day. In her hand was the letter from the South African Catholics Bishops Conferences (SACBC) notifying the Lourdes Mission, where Sr Krystyna is a consecrated sister of the Koinonia John the Baptist community, that funding for the two-year-old Koinonia Orphans Project she headed up, would run out by the end of September.

“Sometimes when we call special meetings it’s because we have been given unexpected donations of blankets, mattresses or something, so the caregivers were very excited. But instead I had bad news to tell them; it was terrible,” she says.

That official funding has dried up and it has been a blow. But the Lourdes Mission has fought to continue with the project even though for the past few months paying the R35 000 a month bill it costs to run the project has never been a certainty

“Prayers and providence,” says the irrepressible Sr Krystyna with a smile, at how donations have materialised. Still, she’s only too aware that the long-term sustainability of the project is in jeopardy.

The Koinonia Orphans Project has over the last two years become a vital lifeline for over 900 children registered in the project and their families from the 13 villages that surround the mission station. The 30 caregivers who receive a stipend for their service also rely heavily on this source of income.

The project that started in October 2015 focuses on supporting children in vulnerable households, many are AIDS orphans. It’s part of the Catholic Church’s response to HIV/ Aids that was officially started in the country in 2000.

Withdrawal of PEPFAR funds

The SACBC has been a beneficiary of the United States’ Pepfar (President’s Emergency Plan for Aids Relief) funding since the fund came into being officially in 2004. The shift in foreign policy under the Trump administration has however, sparked concern for critical long-term financial support from Pepfar.

According to Mrudula Smithson, director of the SACBC AIDS Office, Pepfar funding to the SACBC has been reduced by around half for the next financial year. While Smithson says they don’t disclose the actual amounts, she says their projects have been hit badly.

“We receive three streams of Pepfar funding for our projects that all focus on

The home headed by Christina
Mtolo (far right), her daughter Gloria
Mbhele (far left) and with them
Gloria’s children Anelisiwe Mbhele,
their friend Thembalethu Tshabalala,
and Gloria’s other child Senelweko.
They are one of the families that are
part of Koinonia Orphans Project.

orphaned and vulnerable children – all three have been severely affected while our target of the number of children we want to reach has increased significantly,” she says.

Smithson adds that the SACBC Aids Office programmes currently reaches 45 000 children. “We are very concerned that the small projects around the country especially now have to find their own way to fund their programmes or they’ll have to shut them down,” she says.

At this point, Pepfar will continue to fund projects in South Africa till September next year. In May, the US Embassy in Pretoria announced that Pepfar would support South Africa’s HIV/AIDS and TB programmes till September next year and would support the National Strategic Plan (NSP)’s 2017-2022 programmes for HIV, TB and Sexually Transmitted Infections. An additional U$51-million in funding was approved to support South Africa’s voluntary male medical circumcision programme. Since 2004, Pepfar has invested over U$5.6-billion in South Africa.

A million realities away from decisions made in boardrooms in capital cities, Koinonia Orphans Project caregivers must still get on with visiting families under their care.

Giving care

With basic training in nutrition, hygiene and counselling, caregivers help make sure people adhere to their medicine regimes and have food to eat, often they share from their own meagre provisions. They cook and clean, fix homesteads, and help plant food gardens. They also help register children for birth certificates and identity documents. They do school monitoring, help with homework and ensure that children have school uniforms, without which they’re not allowed to attend school.

Another prong of the Koinonia Orphans Project has been twice yearly voluntary HIV/AIDS testing and counselling days targeted at children but also reaching adults who live in communities surrounding the Lourdes Mission.

In their last testing campaign held in August they were able to test 400 people, working in collaboration with local clinics that provided the pin-prick test kits.

“Knowing their status early is important so that they can start treatment early,” says Gloria Tsezi, one of the Koinonia caregivers in the village of Moyeni.

Tsezi visit homes where the burdens facing families is heavy. At the home of Busisiwe Khambula and her three children, Tsezi looks on as Khambula cradles in her lap the head of her eldest of three children, Olwethu (18). He is severely disabled and often suffers from uncontrollable fits.

“Sometimes the clinic tells me there are no medicines for his fits, then I have to go to Rietvlei Hospital. Sometimes I just lie him down flat and wait till the fit is finished – it hurts my heart too much,” Khambula says. Transport to get to the hospital costs her R200.

Tsezi and Khambula also tell of Khambula’s allegedly abusive relationship with the mostly absent father of her children. Abuse is another load that women in this remote district of KZN must carry.

Tsezi says: “He threw away all her pots and burnt all the children’s documents so I had to help get new identity documents for the children.

“I come to look after Olwethu and the two smaller children, Jabulile and Simthanda, when Busisiwe must go out. I give Olwethu soft porridge and milk, it’s the only thing he can eat – he likes it,” she says, proudly wearing the sky-blue Koinonia golf shirts that have become the uniform of the projects’ caregivers.

A difficult life

A few villages away in Riverside, a mother tells of her trials of living with HIV and the devastation of some years ago when she found out that one of her children, an 11-year-old girl, is also HIV positive. The child has also suffered from TB, she says.

They have a vegetable garden but sometimes there isn’t enough food for a square meal – essential for those taking ARVs. Riverside was also without water for nine months this year.

In another village Tryphina Mkalane is grieving for her daughter who died just months ago. It’s added two more grandchildren under her care, bringing to five the number of young ones who live in her rondavel.

One of the children turns 18 soon. Mkalane worries she will not find a paying job. At the same time it will mean she’ll lose a social grant that goes towards paying for groceries, transport and school supplies.

“One of my other daughters is in Durban. She’s been trying to find a job for over a year now. We send her the grant money so she can pay rent in Durban,” says Mkalane, speaking through her caregiver, Lucinda Dlamini.

For Sr Krystyna, who grew up in Poland and arrived in South Africa from Spain first in 2013 then permanently since April 2014, helping to lighten people’s challenges bought on by the collision of multiple miseries has become part of her life’s work.

Every sad story breaks her heart, but not her faith. Her childhood fascination with Africa has turned into the place she now calls home. In return the community has embraced her as their own, there are even little girls bearing her name – spelt the Polish way – the mothers and the nun say with a laugh.

It was in 2010 that the arduous process of rebuilding the Lourdes Mission and their cathedral first started under invitation by the local bishop to Father Michal Wojciechowski, who now heads the Koinonia John the Baptist community in Lourdes.

The mission station and cathedral date back to 1895. They were built by Trappist monks but had been given over to neglect and abandon for decades. Brick by brick the community has worked to rebuild the twin-towered cathedral and the living quarters for the handful of nuns and brothers who keep the mission alive.

There’s still a mountain of work to be done, like restoring a burnt out convent and an adjoining boarding school.

Every day there are new needs that present at the Lourdes Mission’s doors. The sisters, brothers and Father Michal open their arms to it all: a woman and her children who have gone three days without a meal; the shattering news of a teenage suicide; someone needing help with homework or just seeking out comfort and a prayer – and of course, the on-going question of how to fund the Koinonia Orphans Project for the the long-term.

But the cathedral is a beacon of joy and spiritual light. It’s packed to capacity for Mass each Sunday, the mission’s food garden and orchards now thrive as a symbol of new hope. Funding is sorely needed here; faith in action though, grows with abundance.

BURDEN OF THE GENERATIONS

When the rain sweeps in over the hills of Umzimkhulu and the winds follow, the rolling hills turn to mud and muck. Mist and chill wrap around rondavels with little forgiveness.

Gogo Alexsia Njilo (95) calls this remote part of southern KwaZulu-Natal

95-year old Alexsia Njilo can barely look after herself and says here two teenage grandsons don’t give her much assistance.

home. On a soggy, cold afternoon, the nonagenarian tends a steel teapot warmed on burning firewood in the centre of her rondavel. In-between she shoos away chickens pecking on the dung-mud floor, also seeking the mercy of warmth. Njilo lives with two teenage grandsons here that she mumbles are no good and no help to her. They come and go as they please, she says.

“I won’t cook tonight because they will just eat all my food,” she says in Zulu, I will drink tea for my dinner, she says.

So much adds to Njilo’s hardships: maladies of old age; few opportunities or hope for young people in this remote village and little infrastructure and resources to make life easier for a family living in poverty in the Harry Gwala district. The district has been in the news of late for political killings, cases of corruption and municipal mismanagement, also lack of infrastructure and pressing needs for basic services.

Njilo’s is one of the vulnerable households under the care of the Koinonia Orphans Project, run by the small community of consecrated sisters and brothers from the Catholic Church’s Koinonia John the Baptist community, based at the Lourdes Mission in a neighbouring village.

The 95-year-old’s Koinonia caregiver is the newest and youngest in the project: 19-year-old Thembile Dzanibe, who joined them in the middle of November.

Dzanibe finished her matric in 2016 and had been looking for work ever since.

“Many young people are in the same situation as me. Here in the rural areas there are no jobs or opportunities, nobody has work, they just have to sit at home. I applied for bursaries to study but I wasn’t accepted,” she says.

Added to this she says there’s a growing drug problem and a deep-rooted crisis of alcohol abuse that often leads to violence and criminality. Teenage pregnancy is also common and HIV/AIDS continue to ravage the community.

As a born-free, Dzanibe had hopes of studying to become a teacher. She says: “Actually my dream is to open a crèche, I love children.”

But both dreams have stalled.

“I’m happy to be a caregiver this year, I think I will be able to look after Gogo and the two boys, even though I don’t know if they’ll listen to me,” she says, sitting inside Njilo’s hut.

Gogo’s face does light up to greet her young caregiver but she’s also lost to tiredness and her own thoughts.

For Bertha Mia, the co-ordinator of the Koinonia caregivers, the role that Dzanibe has committed to is a big one.

“You need patience to do this job; you also need to treat every person with dignity. You have to work hard and be honest,” says Mia.

Dzanibe nods as Mia passes on this advice.

Community caregivers take on an intimate, sometimes almost impossible task. They’re a pillar that props up the most vulnerable in society, yet as in the case of the Koinonia Orphans Project they’re also first to fall when funding dries up.

 

Hospital horrors

Lotti Rutter & Leonora Mathe, Treatment Action Campaign

The hospital is full. Two young girls lie on trolleys in the main hallway. They are

An elderly patient with severe pain waits in the corridor at Kwamhlanga
hospital inMpumalanga
without being attended to. The patient’s face has been blurred
to protect their identity.

wrapped in pink blankets; drips come out of their arms and hang on the walls. One looks in severe agony. She calls out for a nurse again and again. Their mother tells us that they arrived at the hospital seven hours ago and have yet to leave the hallway. Laughter comes from the nurses’ break room. It is situated directly opposite their trolleys, but no-one ever emerges to help.

An old man with only one leg sits next to them. His drip is attached to the same set of hooks. He stands in pain. He struggles with his crutches, his drip and his file in order to slowly move down the dusty passage to the toilet. The toilet will not flush, and is dirty after people have tried. A poster haphazardly taped to the wall in the bathroom informs patients that they should “always wash their hands”. Yet the soap dispenser is empty, and there are no taps to provide water. The floor is filthy.

Overcrowding, dirty facilities, bad services and poor attitudes. This is what awaits public healthcare users at Prince Mshiyeni Hospital in Umlazi, the largest township close to Durban.

Treatment Action Campaign branches monitor the state of health care at hundreds of clinics and hospitals across the country. They are the people who need the public healthcare system to work, so they are the first to notice when it does not. Prince Mshiyeni Hospital is not alone in its dysfunction. In recent weeks, a TAC fact-finding mission has showcased the crisis in several public hospitals.

We visited hospitals in KwaZulu-Natal, Limpopo, Mpumalanga and Gauteng. And the situation in each is as dire as it is in the next.

In Limpopo, at Malamulele Hospital, people begin queuing at the old and run-down facility from 5.30am. The corridors are full. At each turn, brightly dressed women fill the hallways. Around 200 people are waiting to be attended to by only two doctors. The waiting is unbearably long. We are told that there has been no constant water supply at the hospital for three years. Patients are unable to wash themselves, and there is only a small amount of container water available for using the toilets. As we walk through the wards during visiting hours, the patients have no privacy. There are no doors or curtains. The wards smell, and the bed linen is dirty.

In Tshilidzini Hospital, more than 75 patients wait for their files. Each time a shrill voice screams out a name, the chain of people patiently moves one seat across. People have been waiting in this queue for over five hours. A few people waiting are already wearing Tshilidzini hospital gowns. One is a young man with an open wound on the back of his neck – the wound and stitches are uncovered, and he uses a wad of toilet paper to stop it seeping. And the file room is only the beginning; once they leave, patients are faced with more long queues to be attended to by a doctor.

In Elim Hospital, patients wait for files for around five hours. After collecting their files, they enter the hospital and join a long queue to be seen by a doctor. In a corridor around 100 metres long, patients on back-to-back benches fill the entire space, waiting to be seen. Those with bad coughs sit with everyone else – in a corridor with windows on just one end. As we walk around, at each turn a new queue appears. More faces are raised in hope at the sight of us. In the main hallway, a man is sitting on a trolley, under a blanket. A drip comes out of his arm. He tells us he was admitted six hours ago, but nurses have yet to find a bed for him to be moved to.

In Mpumalanga, at KwaMhlanga Hospital, the corridors are full. One old gogo

Welcome to Prince Mshiyeni Hospital. Expect long waits,
bad service and dirty facilities.

(elderly lady) lies on a trolley in the corridor, in severe pain. She struggles to move, and has not yet been attended to. People in wheelchairs are stacked together, each man’s knees squashed into the chair in front of him. Hundreds of people wait to be seen. Their eyes follow us as we pass through the corridors. One man sits in casualty with a home-made sling on his arm. After being attacked by thugs, he had attempted to access services at the hospital. An X-ray had been taken the night before – yet only a day later, his file has been lost. He is told to go and submit an affidavit at the police station, and return. He has no money, and has received no painkillers. The young man sitting next to him has been waiting for five hours. A baseball cap covers a bloody stain on the back of his head.

In the most well-resourced province, Gauteng, the recently refurbished Thelle Mogoerane Hospital still suffers the same level of neglect as before. Casualty is overcrowded, and the queues last for hours. People sleep in the corridors. Patients bleeding and in critical condition sit with everyone else. A psychiatric patient is seen wandering around the wards. We are told that for days, patients have been fed porridge for every meal. One woman shows us an X-ray of her broken jaw. She had been sent home with just a Panado for the pain. Another woman told us that post-labour, the doctors had sewn her vagina shut – when she returned to question them, they told her she must have been born that way. Another woman explained how, during labour, doctors took another woman into her space in theatre. Eventually, after waiting the whole day to be seen, she gave birth to her baby. The baby was green, and died six days later.

Poor management, budgetary constraints and a lack of care for the needs of patients plague these public facilities. And it is the people who suffer. In order to expose these crises, and hear from the people who need to use these services, TAC will be holding public hearings and showcasing people’s stories in the run-up to World AIDS Day.

As we leave Prince Mshiyeni Hospital through the abandoned trolleys, a woman sits sobbing in a wheelchair. Under a blanket her feet are badly swollen, and she struggles to breathe. We can see the fear in her eyes. She has just been discharged. A nurse leaving the hospital passes by; we try to engage with her to re-admit the woman, but she informs us as she rushes away that she will let the security guard know he must look for the woman’s friend. After TAC intervenes, she is re-admitted. Upon being examined, she is diagnosed with pneumonia and cryptococcal meningitis. She is moved to a cold and overcrowded ICU ward, beds mere centimetres apart. She has not been allowed to keep her blanket, and is visibly shaking when we visit.

When we eventually leave the facility, the young girls cocooned in pink are still where we found them in the dirty corridor, hopeless, still waiting for help.

A litany of atrocities at Prince Mshiyeni Hospital
- A wheelchair lies abandoned on the pavement, and trolleys are scattered across the casualty entrance of the hospital. Dirty rags line the floors as we enter. We are greeted by dust, dirt, and dirty chip packets.

- Family members push patients up and down the hall on trolleys. One patient looks in severe pain, lying on her side on a trolley; she rests her head on a water bottle that acts as a pillow.

- A diabetes patient waits to collect chronic medicines. Last month she waited through the day until 11pm, only to have to return the next day. Before speaking to us today, she has already waited for over eight hours.

- Paper files lie on the unattended counter for anyone to look at. One woman waited for eight hours until they located her file.

- At 4.30pm, more than 100 people still need to be seen. Every corridor of the hospital has more and more patients, sitting, waiting to be attended to.

- One small room has at least 25 beds haphazardly squashed into it. Another has only a few centimetres between each bed. It seems that psychiatric patients have been put next to other patients.

- A woman with her leg in a cast had come to the hospital in agony seven hours prior, in an ambulance. The previous month they had cast her leg without having taken an X-ray. At 4.30pm she is told the X-ray department has closed, and she should return the next day. The doctor has not seen her. As she leaves the hospital in a wheelchair, she is still in agony. In her opinion, coming to this hospital is a waste of time.

- Three people struggle to get an unconscious person – who has been discharged – into the back of a car. They use a piece of material to get the person off the trolley, and eventually, onto the back seat. During this 20-minute challenge, cleaners look on.

- An old man, looking gaunt and sick, leaves the hospital. A pulled-down TB mask rests on his neck.

- A hungry man eventually leaves the hospital by getting a lift with strangers. He has been there for eight hours. He has no money for food or for a taxi.

- A white van emblazoned with a “21st Century Funerals” logo stands outside the accident and emergency entrance. A trolley is carried out of the back and taken inside the hospital. A while later the driver returns, pushing a corpse in a body bag past patients entering the hospital in order to load it into the back of the van.

New SANAC CEO responds to questions about his past

By Ufrieda Ho

Dr Sandile Buthelezi was recently appointed as the new head (CEO) of the South African National AIDS Council. His appointment follows the suspicious non-renewal of the previous CEO’s contract Dr Fareed Abdullah and unsuccessful attempts to lure Eastern Cape head of health Dr Thobile Mbengashe to the post. The success of the new National Strategic Plan implementation and the long-term survival of a robust, relevant and ethical SA National AIDS Council will depend on the new CEO. Spotlight put a range of questions to Buthelezi regarding his involvement in the Tara KLamp debacle, the persecution of doctors at Manguzi Hospital in 2008, and allegations of corruption.

Dr Sandile Buthelezi was recently appointed as the new Chief Executive Officer (CEO) of the South African National AIDS Council (SANAC). Buthelezi’s appointment comes as a surprise, given that it was expected that the position would go to Thobile Mbengashe – who Spotlight understood to have been the preferred candidate of key members of the SANAC board of trustees. However, we understand the Eastern Cape made Mbengashe a counter offer, which made it hard for him to leave for the SANAC job.

Buthelezi’s appointment also surprised activists who are concerned about his involvement in the rollout of an unsafe circumcision device (the Tara KLamp) in Kwazulu-Natal and the persecution of doctors at Manguzi Hospital in 2008. The doctors were providing dual antiretroviral therapy to pregnant women with HIV. At the time providing dual therapy was deemed to be against the government policy of AIDS denialist President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang.

Highly charged atmosphere

Buthelezi is stepping into a highly charged atmosphere with recent news reports describing SANAC as being in disarray and various civil society organisations considering a withdrawal from SANAC. Some of the concerns regarding governance at SANAC relate to the process of appointing a new CEO. For reasons that have not yet been explained, an initial recruitment process was stopped halfway and the post was readvertised early this year. In February this year the trustees, then led by Dr Gwen Ramakgopa, who is now Gauteng MEC for health, announced that Dr Malega Constance Kganakga had been appointed acting CEO for three months while interviews were being completed. It would be another four months (after those initial three months) before Buthelezi took office at the beginning of September 2017.

The board controversially decided in February not to extend the CEO contract of Dr Fareed Abdullah or to allow him to continue as interim CEO. This move was met with widespread condemnation from activists and the Democratic Alliance. Abdullah is credited by some for transforming SANAC into an independent Council that for the first time had five straight years of clean audits and better checks and balances in place to ensure good governance.

Buthelezi told Spotlight he wishes to thank his predecessors “for building SANAC into the credible organization that it is”. “SANAC operates against the backdrop of people’s perception of government institutions and hence our first duty will be demonstrating good corporate governance,” says Buthelezi. “This is a critical obligation that we at SANAC need to uphold, and it will be the hallmark of my tenure.

Persecution of Manguzi doctors

In 2008 Buthelezi was head of HIV and AIDS in KwaZulu-Natal where he played a role in the persecution of doctors at Manguzi Hospital. Dr Colin Pfaff, acting medical manager at Manguzi Hospital at the time, and colleagues broke rank from official Department of Health policy to introduce dual-therapy treatment for HIV-positive pregnant women at a time when official government policy was to provide only monotherapy.

The science at the time was clear that dual therapy was superior to monotherapy in reducing mother-to-child transmission of HIV. Pfaff raised funds from donors to pay for the introduction of dual therapy at Manguzi. Pfaff was suspended for this and faced disciplinary action – that was later withdrawn.

Buthelezi admits he worked closely with doctors in the district at the time and adds: “I believe it is unfair to expect a junior official to act out of sync with national government policy.” At the time Buthelezi was quoted making a similar argument in the New York Times saying “I am wary of us undermining national just because of what other provinces are doing (referring to the rollout of dual therapy in the Western Cape)”. At the time Buthelezi was working under controversial KwaZulu-Natal MEC for Health Peggy Nkonyeni – who was a close ally of AIDS denialist Health Minister Dr Manto Tshabalala-Msimang.

No regrets regarding Tara KLamp

In 2010, Two years after the Manguzi scandal, with government-sanctioned AIDS denialism having meanwhile “ended” under the leadership of first Health Minister Barbara Hogan and then her successor Dr Aaron Motsoaledi, the Kwazulu-Natal Department of Health was involved in another high-profile controversy. The department started providing circumcisions with an unsafe plastic circumcision device called the Tara KLamp. The device caused a number of serious injuries and eventually became the subject of a Treatment Action Campaign complaint to the Public Protector. Questions about alleged kickbacks relating to the procurement of the Tara KLamp remain unresolved seven years later.

While Buthelezi wrote letters and was quoted in the media in relation to the Manguzi scandal, it appears he was less directly involved with the Tara KLamp rollout. Another Sandile, Sandile Tshablalala, was in charge of the circumcision programme in the province. As with Manguzi, the Tara KLamp had high-profile political backing  this time in the form of MEC for Health Sibongiseni Dhlomo, then Premier of Kwazulu-Natal Zweli Mkhize, and King Goodwil Zwelithini.

Yet, as head of HIV and AIDS in the province Buthelezi would have almost certainly been party to decisions made regarding the rollout of the Tara KLamp. We can find no evidence that he opposed the rollout in any way – this while he admits involvement in the circumcision programme. “I am proud of my contribution to the roll-out of medical male circumcision in KwaZulu-Natal,” says Buthelezi, wwhich included (…) Rallying all stakeholders including His Majesty, in advocating for MMC.”

“The implementation of medical male circumcision in the province remains a watershed moment in the country’s HIV response,” he says. “A province where circumcision was not routinely practised, took the lead in including medical male circumcision as part of a combined package of prevention methods. This is a significant achievement and I have no regrets.”

Corruption allegations

In late 2010 Buthelezi left the KZN Department of Health. A source suggested to Spotlight that Buthelezi’s departure was related to allegations that he awarded a catering contract to a family member.

While Buthelezi does not dispute that the allegations were made, he insists that they are baseless and untested. “The issue relates to a tender that was dealt with at a district where I was not involved in any of the bid committees,” he says. “I only received paper work to approve payment after the district committees and management had signed that they received the goods and/or services.”

Buthelezi says he left the KZN Department of Health because he received a better job offer and that he continued to have a good relationship with the department after he left. He took up a position as country director of ICAP, a University of Columbia initiative to strengthen health systems around the world. From there he left to work at HLSP- Mott MacDonald, as senior technical lead with the health sector consultancy. In 2014 he was reappointed to the ICAP role.

“He will have to build trust”

Several of Buthelezi’s previous colleagues, members of the SANAC board and people he had professional dealings with at his previous positions were contacted to comment on Buthelezi’s appointment. Some didn’t respond and some declined to comment on record. Professor Wafaa El-Sadr the director of ICAP, based in New York, did comment, saying that in the last three years that he reported to her that Buthelezi did meet specific implementation targets and successfully built important linkages and partnerships within his team. “He had a good understanding of the lay of the land. He had the experience and he did understand South African realities.

“The challenges for a strong SANAC will be about never losing sight of the core of what we do and that is to change the lives of people. He will have to build trust and be able to bring along with him even those people who are not supportive of him,” says El-Sadr.

“He was on the wrong side”

Anele Yawa, General Secretary of the Treatment Action Campaign, says that Buthelezi’s past cannot be ignored. “He was on the wrong side – he was an AIDS denialist, like Manto Tshabalala-Msimang and Thabo Mbeki, he wasn’t for the people,” he says.

“We don’t just want a warm body in the position of CEO and we still don’t know what happened with the process of appointing a new CEO,” says Yawa. “Buthelezi must be able to add value. He can start with audits of the organisations that are part of the SANAC civil society sector – he can even start with TAC, this will make it clear who should be part of SANAC and who should not.”

Yawa says SANAC has to return to the grassroots – the face of HIV/AIDS, not be fixated on “meetings and conferences held in fancy hotels”.

Even with his outspoken criticism, Yawa says that for now TAC remains committed to staying within SANAC. “We want to fix the problems because we have come a long way. But when we ring the bell Buthelezi must come. We give him three months to get his house in order,” says Yawa.

“I believe in service”

Buthelezi says his vision for SANAC will become clearer once he settles into the role. But he says he’s up to the job. “I come from rural eShowe where humility, respect and ubuntu define human relations,” he says. “We’ve fought HIV for too long – we must see results.”

“I believe in service and I am results-driven and work well with teams. I hope we shall be an organisation that listen actively, prioritises what’s important, adapts readily and empowers others.”

 

TAC survey highlights poor infection control in clinics

By Marcus Low

Tuberculosis (TB) infection control measures in some South African public sector clinics fall woefully short. This is according to an infection control survey that was published by the Treatment Action Campaign (TAC) ahead of World TB Day (23 March 2017).

While the survey has some limitations, and is by no means an exhaustive survey of clinics in South Africa, it nevertheless provides compelling evidence that we have an infection control problem at a number of public sector clinics. Given that poor infection control at clinics may be a significant contributor to TB transmission in South Africa, this is a red flag that should be taken seriously.

How was the survey conducted?

TAC branch members across seven of South Africa’s nine provinces were trained on a TB infection control questionnaire. Delegations from TAC branches then went to their local clinics to fill in the questionnaire. They reported their findings back to the TAC national office where the findings were captured.

The questionnaire contained seven questions relating to TB infection control measures that should be in place at clinics. Each question was simply given a “yes” or “no” answer. It was designed in such a way that “yes” answers in each case indicated correct infection control procedures. In other words, the more “yes” answers a clinic got, the better.

What did the survey find?

As part of their media release, TAC published an Excel file with the data they collected. This file contains details of the 158 clinics that were surveyed and how each of seven questions were answered in relation to these clinics. Below we present some additional analysis we conducted of the data provided by TAC. (For those interested in exploring the data, we have done some data cleaning and saved it as a CSV file that can be downloaded here.)

While TAC rated each clinic red, orange, or green – the data can also be represented as a score out of 7 for each clinic – where each yes answer adds 1 point to the score. Thus clinics that score 7/7 are rated green, 5/7 or 6/7 are rated orange, and 4/7 or less are rated red.

Scores by province

ProvinceNumber of clinics surveyedMean score out of 7
Western Cape 15 4.67
KZN20
3.85
Eastern Cape253.52
Free State193.16
Limpopo233.0
Mpumalanga392.92
Gauteng172.88

The above table shows the mean score of the clinics surveyed in each province. We should stress though that these are not representative samples and the findings cannot be generalised to entire provinces. The mean scores in some provinces are also so close together that we should not read anything into the fact that e.g. Mpumalanga is above Gauteng, or that Free State is above Limpopo. It does seem significant however that the clinics that were surveyed in the Western Cape tended to do substantially better than clinics surveyed in other provinces.

No clinics in the North West province and the Northern Cape were surveyed. Of the seven provinces surveyed, Mpumalanga is somewhat over-represented with 39 out of the 158 clinics – most other provinces had around 20 clinics surveyed.

Results by question

This table shows the total NO and YES answers to the seven questions. In each case YES indicates correct infection control measures. Only question 1 and 3 received more than 50% YES answers. Question 5 received exactly 50% YES answers.

QuestionsAnswered NOAnswered YES
1. Are the windows open?22136
2. Is there enough room in the waiting area?9266
3. Are there posters telling you to cover your mouth when coughing or sneezing?6494
4. Are you seen within 30 minutes of arriving at the clinic?10157
5. Are people in the clinic waiting area asked if they have TB symptoms? 7979
6. Are people who are coughing separated from those who are not?10553
7. Are people who cough a lot or who may have TB given tissues or TB masks?11642

The TB infection control measure on which clinics did the best was keeping the windows open in the waiting area. Second best was having posters up on the walls telling people to cover their mouths when coughing or sneezing. However, apart from opening windows and having posters on the walls most clinics did very poorly at TB infection control.

It is also notable that on the cross-cutting question as to whether people are seen within 30 minutes, only 57 of the 158 clinics got “yes” answers. Long waiting times becomes a more important risk factor when other infection control measures are not in place because people are exposed for longer periods. The mean score in clinics with less than 30-minute waiting times was 5.1 compared to only 2.3 in clinics with longer waiting times – in other words, the clinics where people waited longer tended to be clinics where the risk of TB infection were already substantially higher.

How much did clinic scores vary?

Only 15 of the 158 clinics in the survey got “green” ratings. 31 were rated “orange” and 112 were rated “red”. The mean rating for all clinics surveyed was 3.34/7 and the median was 3/7.

Hearing a problem, and solving it

By Ntsiki Mpulo

Nombulelo Sojina* cradles her baby close to her chest in a kangaroo mothering-style of skin-to-skin

Air Mercy Services has provided doctors with essential transport and support to deliver specialist outreach services to remote regions in Kwa-Zulu Natal and through-out the country for over 50 years.
Air Mercy Services has provided doctors with essential transport and support to deliver specialist outreach services to remote regions in Kwa-Zulu Natal and through-out the country for over 50 years.

contact. The child’s tiny head is barely visible under the blanket in which she is swaddled. Two nursing sisters, tasked with conducting hearing screening tests on newborns, enter the maternity ward in which Sojina and her baby are resting. They explain that they need to insert a scope into the baby’s ears to determine whether she has any impairments.

‛Sojina’s baby was born prematurely, at just 30 weeks, and so the screening for hearing impairments is all the more crucial,’ says Ayanda Gina, an audiologist who is pioneering the newborn hearing screening programme at the Newcastle Mother and Child Hospital. The programme, which will help to identify hearing defects in children at birth, is part of Gina’s research towards her doctoral thesis.

She is working with Doctor Yougan Saman, Head of Discipline: Otorhinolaryngology and Head & Neck Surgery at Nelson R Mandela School of Medicine, University of KwaZulu-Natal. Although her training is in audiology, Gina dreams of following in her mentor’s footsteps and becoming an ear, nose and throat specialist.

Dr Saman has been involved with the KwaZulu-Natal Department of Health outreach programme since its inception. He regularly flies with Air Mercy Services (AMS) from Durban to support the doctors based at regional and district hospitals throughout the province. As head of the department, his main focus is to develop the services at these hospitals in order to alleviate congestion at tertiary hospital level.

‛When we started the outreach programme, I travelled to Newcastle Hospital by car,’ says Saman. ‛The three-hour journey was arduous and time consuming. I would drive up in the evening stay overnight, see patients for the day and drive back the following day, taking three days out of my schedule.
‛Now I’m able to make the trip in one day,’ he says. ‛With the support of AMS, we are able to give specialists the ability to work immediately and to develop skills in local doctors.
‛Essentially, this is what I have done with Ayanda. She has assumed more and more responsibility not only because she is keen to learn but because I have been able to impart on her the skills to enable her to drive this programme,’ says Dr Saman.

Gina supervises two enrolled nurses, three in-service personnel and a community service therapist within the hospital’s premises, and conducts outreach missions into the surrounding villages regarding hearing health for children. The World Health Organisation (WHO) estimates that there are 360 million people (328 million adults and 32 million children) worldwide with disabling hearing loss.

The WHO makes a distinction between congenital and acquired causes of hearing loss and describes congenital causes as those that may lead to hearing loss being present at or acquired soon after birth. These include maternal rubella, syphilis or certain other infections during pregnancy (low birth weight or a lack of oxygen at the time of birth) and severe jaundice in the neonatal period, which can damage the hearing nerve in a new-born infant.

In its latest fact sheet, the WHO states that half of all cases of hearing loss are avoidable with primary intervention. It is at this level that the teams hope to make an impact. The aim of the research is not only to identify potential hearing loss at an early stage but also to provide support for families whose children are identified to have hearing disabilities, including psychologist support and school assessment options.

‛If children are screened early enough, they may not need special schools,’ explains Gina. ‛With the right treatment, which may include hearing aids and speech therapy, we are essentially giving children the ability to communicate, which is crucial for their development.’
*Not her real name

Communities in crisis

By Treatment Action Campaign

The Treatment Action Campaign has shared the following stories with Spotlight from their provincial operations in KwaZulu-Natal, Limpopo, Mpumalanga and the Free State. Elsewhere in this issue of Spotlight we take an in-depth look at Gauteng – which is therefore not included here.

France, KwaZulu-Natal

france-kzn1
Branch members go door to door in France to find out how people in the community cope without a clinic.

The community of France in KwaZulu-Natal does not have a clinic. A mobile clinic comes to the community just once a month. But most people don’t use it; some don’t even know about it. Instead they travel by taxi to other clinics – if they can find the money. Sometimes they must lie about where they live in order to see a nurse, or they simply go without medicines and health services altogether. Only certain community caregivers can deliver medicines to patients, if they have an ID, and if the patient is being treated at the mobile clinic. The rest, however ill, have to collect medicines themselves. It seems people are defaulting on ARVs, TB treatment and other chronic medicines as a result. We can never have #treatment4all – or #EndTB – when people can’t even get to the clinic. TAC members have asked the people of France how only having a mobile clinic affects them. The resounding response is that once a month is not enough. To resolve service deficiencies such as this one, which keep the dual epidemics burning, health system challenges must be addressed in the National Health Department’s test-and-treat plan and within the new National Strategic Plan on HIV, TB and STIs. Otherwise we are doomed.  #FranceNeedsAClinic.

Khujwana, Limpopo

Within a few hours of walking door to door through the streets of Khujwana it is clear there is a major problem. Every home has a story to tell – a story of frustration and suffering, a story of failure.

While the local clinic looks functional, even ‘pleasant’, from the outside with its solid infrastructure and garden, inside it s a totally different matter. Many patients report ongoing stockouts and shortages of their medicines. They wait for hours before being seen by anyone – there is a shortage of nurses and no doctors ever come. Some go to other clinics altogether. People report incidences of nurses treating them badly, being rude or, worse, negligent. Mothers report the indignity of having been mistreated, or unattended to, in the midst of labour. Khujwana Clinic is failing the people and the community it is meant to serve. Tired of this situation, the community is mobilising. Testimonies from community members who try to use the clinic are being gathered. Local stakeholders are coming together to draw attention to the major shortcomings. All they want is a clinic that can give them the health-care services they need. They are clear: They will continue to escalate this issue until they #FixKhujwanaClinic.

Boekenhouthoek, Mpumalanga

The local TAC branch in Boekenhouthoek receives ongoing complaints about the local clinic. People

In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.
In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.

report waiting for long periods of time, with or without being seen. There aren’t enough nurses stationed in the clinic exacerbating this issue. The clinic is too small, and people wait outside while waiting to be seen. The clinic is faced with regular stockouts and shortages of medicines meaning people are often sent home empty handed. Some community members choose to go to different clinics altogether. A luxury that many of those unemployed people who live in the area cannot afford. Traditional leaders confirm these conditions, from personal experience. One woman spoke of never receiving a TB diagnosis, months after taking a test. One man spoke of misdiagnosis. Another had never been told he had HIV, yet had been prescribed ARVs for more than four years with serious side effects. People reported of nurses being rude to them in moments of severe vulnerability. The TAC Boekenhouthoek branch is monitoring the clinic and gathering information from residents about the challenges they face. How can we reach #treatment4all if clinics run out of medicines? Or if people don’t want to use them because of the lengthy waits and poor service? The reality is that the dysfunction in our health-care system will stop the new HIV guidelines on test-and-treat from being a success. We need significant investment into stronger systems in order to respond to the HIV and TB epidemics. #BetterBoekenClinic

Phuthaditjhaba, Free State

Members of the TAC in Phuthaditjhaba have reported serious problems at Manapo Hospital that are putting people’s right to access health care in serious jeopardy. This report followed a strike by frustrated, overburdened staff members, including doctors, nurses, physiotherapists, porters, cleaners, and kitchen staff, who claimed to have not received pay for significant amounts of overtime since 2015. TAC members investigated the hospital and spoke to many patients entering and exiting the facility. Reports of long waiting times, a lack of nurses, doctors, and other staff being stretched beyond their capacity, and medicine shortages, were common.

After being stabbed in the forehead, one teenager reported not seeing a doctor after seven days of waiting. Another teenager had been stabbed in the upper chest four days earlier. He was also still waiting to see a doctor. A woman with a homemade sling and swollen wrist left the hospital in pain to return to the clinic. One man, falling in and out of consciousness, was told to return to casualty with a referral letter. Outside the hospital, visibly injured patients could be seen wandering the grounds in their pyjamas. After taking a rest on the grass, one young man with bandages across his face struggled to stand up and had to be assisted by two other patients to get onto his feet before limping back inside. Portable toilets remain outside the hospital after a water crisis the month before. It is unclear whether the water shortages continue. A TAC member helped a man with crutches who struggled to climb up the metal steps to enter the toilet. If urgent action is not taken to turn around this crisis, the TAC will be forced yet again to embark on a campaign of civil disobedience in order to save the lives of those reliant on the failing public health-care system. #FSHealthCrisis

 

 

 

 

In good hands

By Ntsiki Mpulo

Eyes bulging, lips cracked, ribs clearly visible under taut skin; the man appears on the verge of taking his last breath. He speaks in a whisper and, over the din in the emergency room, anyone wishing to have a conversation with him has to lean in close. This is the scene in the emergency room at East Griqualand Usher Memorial Hospital just outside Kokstad in deep rural KwaZulu-Natal.

Doctors are huddled around the man who was brought into the hospital the night before. It seems he had ingested near lethal doses of an unknown substance. His common-law wife of 22 years says he had been taking traditional medicines for several months. She suspects that this is what had led to his severe deterioration over the last few days.

Forty-one-year-old Fikile Ngaleka speaks haltingly as she relates the events that had forced her to have her husband admitted. ‛He started feeling ill around November last year and started getting thinner but all the while still carrying on with young girls,’ she says between bouts of heaving sobs. Her red-rimmed eyes are full of tears. She occasionally covers her mouth as she talks.

‛He went with his sisters to a traditional healer and they came back with some powder that he had to lick twice a day and some kind of pink liquid that he had to drink half a glass of everyday,’ she explains. ‛All of this made his tummy run uncontrollably and I begged him to stop taking these medicines. He would stop for a few days but then start again.’

She pleaded with him to visit the doctor.

 

He either blatantly refused or lied, saying he had gone but that doctors had found nothing wrong with him.

Then, one Wednesday evening, Badanile Thomas Mjojo (47) simply collapsed. He could no longer walk. He was admitted to EG Usher Memorial. He had been diagnosed with HIV, found to have a CD4 count of below 200, and had recently started on antiretrovirals. When he was admitted, his potassium levels were twice the normal levels indicating that he was suffering acute renal failure.

Things were not looking at all good for Mjojo. Few specialists work in deep rural areas like East Griqualand and even if the specialists are there, the state-of-the-art medical equipment is often hundreds of kilometres away.

Yet, thanks to a somewhat unusual government programme, things are looking up for Mjojo by Thursday morning. After a short bumpy flight from Pietermaritzburg to the Bastard Farm Airstrip some 15 km outside Kokstad, Dr Brett Cullis is asked to look at Mjojo’s case. He is in good hands; Dr Cullis is a private nephrology specialist who consults at Grey’s Hospital in Pietermaritzburg. Once a month he boards a small 12-seater aeroplane to EG Usher Memorial, where he provides support to doctors who lack expertise in kidney-related issues.

cullis
Renal Specialist, Dr Brett Cullis with a patient

Cullis quickly determines that Mjojo requires emergency dialysis. He needs to be transferred to Grey’s Hospital in Pietermaritzburg, some 250 km away. Given the advanced stage of renal failure, road transfer is the most appropriate means of getting the patient to the tertiary hospital.

Dr Nigel Hoffman, the Acting Clinical Manager at EG Usher springs into action, calling emergency services personnel to arrange the transfer. But there is a snag. None of the three ambulances based at EG Usher Memorial will be available in time to transport the patient.

‛In his case, there’s not enough time to wait for an ambulance to take him to Grey’s,’ says Dr Cullis. ‛We will start peritoneal dialysis with a make-shift device until he is stable enough for us to transport him to Pietermaritzburg.’

As Mjojo is wheeled the short distance from emergency room to theatre and is being prepared for surgery, the hospital is suddenly plunged into darkness. The power had failed and the new generator, which had been installed just two weeks before, has not switched on.

Dr Hoffman calls the maintenance department. The news isn’t good. It will take over an hour for power to be restored.

Working in the half-light, the doctors make sure the patient is comfortable, with a drip feeding him an essential saline solution to flush his system. With nothing more to be done until power is restored, Cullis attends to outpatients he was scheduled to see before the emergency occurred.

Finally the lights flicker back on. The physicians don their sterilised scrubs and head back to the operating theatre.

‛We cannot risk putting the patient under general anaesthetic – we don’t believe his system would handle it. So we are going to use a local anaesthetic,’ explains Dr Cullis.

He speaks quietly to Mjojo. He explains in broken Xhosa that he will inject his stomach with anaesthetic, make a small incision below the belly button and insert a tube into which he will pump saline solution. Once inside the belly the solution will draw out impurities in the blood through osmosis and will then be drained via the same tube. Ordinarily, dialysis is done with a small 2 mm tube into the blood stream, but without the right equipment the doctors will improvise with a chest tube.

The operating theatre is quiet as the doctors go to work. Mjojo moans in discomfort, the only sounds in the operating theatre apart from the beep of the blood oxygen monitor. Dr Cullis struggles to insert the tube and adjust it to make it into a two-way valve system that would allow for fluid to be both injected and drained. Now and again, a quiet whisper. The tension and focus in the room is palpable.

Finally, after an hour of alternatively widening the site of the incision and placing the tube deeper into the abdomen, the procedure succeeds. The doctors give a muted cheer.

‛I did not want to dig too deep in case I punctured the bowel and so, what would ordinarily take 10 minutes with the right equipment, has taken an hour,” explains Cullis. ‛But this is a good outcome under the circumstances.’

‛Often the issue is that people take too long to come into the hospital and get onto dialysis and, as a result, they die,’ says Cullis. ‛If we had sent him to Pietermartizburg without performing the procedure, he may not have made it.’

For the time being, Mjojo has been stabilised. Soon, the ambulance will transfer him to Grey’s Hospital where he will receive further treatment.

The outreach programme that flies Dr Cullis to EG Usher once a month is not available in all provinces, and in some provinces it has collapsed after previously being functional. Like many public programmes, it has become mired in disputed tenders and the spurious awarding of contracts.

Dr Lindiwe Simelane, general manager for clinical support services in the Kwazulu-Natal Department of Health says the outreach programme is invaluable in the delivery of services to the rural areas of her province. ‛There is a global shortage of medical professionals, and doctors in particular. Our particular challenge is in retaining doctors in rural areas. They come as community service doctors and, once they’ve completed their two years in the public service, they leave,’ she explains.

‛A robust outreach programme is part of the solution because senior doctors and specialists are able to go out into the rural areas and support our young doctors,’ she says. ‛Indeed, we have built teams of roving doctors who are able to provide expertise in their specialisation which we don’t have at a regional and district level.’

‛The idea is that patients should not go to tertiary hospitals until they have been seen at a clinic, and district and regional hospitals. They need to have a referral letter from a general physician seeking specialist care at tertiary level,’ she explains. ‛Part of the outcome for outreach is to decongest the system and to ensure that the referral system works.’

Dr Cullis is pioneering a programme to deliver life-saving kidney dialysis treatment to remote places in South Africa and across the continent using a technique called peritoneal dialysis (PD). Dialysis is a way to remove waste products from the blood when the kidneys can no longer do the job adequately. The most common form is haemodialysis, which involves using a machine to filter the blood ,removing impurities. In many countries, haemodialysis is inaccessible due to cost and lack of infrastructure. A peritoneal dialysis is a procedure that uses the inside lining of the belly to act as a natural filter to perform the functions of a kidney and is much more cost effective, and affordable, for most developing countries.

 

The barefoot soldiers of a public health care system that doesn’t seem to care

By Nomatter Ndebele

For the past 17 years, 55-year old Doris Ntuli has worked as a community caregiver (CCG) in the community of Sweetwaters, in Pietermaritzburg, Durban. In that time Ntuli has only received a pay increase of R300 (US$20). Her total monthly income is R1500 (US$95).

Tireless: Doris Ntuli
Tireless: Doris Ntuli

That one increase was all she’s ever been given. Other than that she and her colleagues work without support or resources in a hostile environment and one which provides little help to the people of the communities they serve.

In 2001, the KwaZulu-Natal province launched Operation Sukuma Sakhe, a social health care model that offers an integrated approach to both social and health-care services. The model puts one community caregiver (or community health worker, as it is generally known in South Africa) in charge of 60 households in order to oversee their health as well as their socio-economic wellbeing.

Care givers report to a “war room” with representatives from various social development departments including Home Affairs, Agriculture, Human Settlements, Health and Social Development. Here they are expected to report any issues affecting their allocated households to the relevant departments, who are then required to intervene, either by going back to the specific household or sending whatever is needed back with CCG.

What should be a strict and formal process however, hardly ever happens. On some days, department representatives don’t show up, and care givers say that not once have they received responses to cases written up in the report books in their absence.

This is one of the reasons CCGs, who are a vital part of the primary health care system, have lost credibility in the community. They never seem to deliver on their promises.

Seven years ago, for instance, on one of her rounds, Doris came across a quadriplegic blind man, who was living in an outside room and fending for himself. Although his family lived with him, they did very little to take care of the man. Doris told the family that she would report the matter and ensure that a wheel chair was delivered to the man.

“For seven years, I went back and forth to that war room to report the matter, but I received no help. I eventually stopped going back to the house because I was so ashamed,” says Doris.

The man died before any assistance came.

For two years now, Doris has left reports at the war room, detailing a case of an improperly sealed sewerage access point.

“It’s not safe. It’s just a big dark hole and if a child falls into that pit, they will be gone.”

To this day, the sewage access point remains open and no one from the war room has responded in any way. Doris admits that she is close to giving up on the matter. Clearly, nobody cares.

Although CCGs are employed as an extra hand for the departments of health and social services, they are met with much resistance. Nurses in the local clinics look down on them, viewing them as uneducated and providing very little support for the work they do.

Over the past six years, civil society has pushed for the government to recognise community health workers as legitimate aides of the public health care system, and calling for them to be formally employed and given the support they need to do their jobs.

Simanga Sithebe, a representative from Sinani, an organisation that works closely with CCGs in eThekwini, says that one of the biggest issues CCGs face is a lack of resources. They have no travel allowance and are not compensated for any expenses.

“They often pay out of pocket to provide patients with money for trips to the hospital or clinic,” said Sithebe.

CCGs are also forced to work with few or no materials. Often, Doris will get a bag of nappies and nothing else – no gloves, no TB masks – but she is expected to do her rounds regardless.

“The nurses tell me that they only have enough stock for themselves, and that we haven’t been budgeted for,” said Doris.

“Even people who clean the streets have a uniform. They have boots, but I walk up and down this community everyday in my sandals until they break,” she adds.

Sithebe explained that dysfunctional administrative processes have an impact on the work of these community health workers. The renewal of contracts is not a well-managed process and CCGs can wait for up to two months to find out whether their contracts will be renewed.

Despite the fact that CCGs are contracted by the KwaZulu-Natal Department of Health on one- or two-year contracts, they receive no benefits at all.

“If I die tomorrow, these children you see here won’t even have 20c to their name” says Ntuli.

For years, the CCGs in Durban have been promised better opportunities, but very few have materialised. When Doris started, she was told that she could be eligible for nursing training. This hasn’t happened, and in the 17 years that she has worked, only two other CCGs she knows have received training.

Doris, and many other CCGs in Durban have tried to have their grievances heard. Their peaceful marches and heartfelt pleas have gone unnoticed.

“I am supposedly working for the department, but not once have I seen a representative come and address our issues. For years they have ignored us,” said Doris.

At the beginning of May this year CCGs in Sweetwaters decided to take drastic action.

Doris joined a group of CCGs who staged a shut down at the local clinic. The group arrived early in the morning and locked the gates of the clinic, denying patients and staff access. It was only after this act of civil disobedience, that the CCGs were promised a response.

Their drastic action was a means to an end, but she and others knew that it will quite likely further strain relations between themselves and staff at the facility.

“We have never had a good working relationship with the sister at the clinic, and after this, I know things will be even worse. But what could we do?”

In spite of all these problems, Operation Sukuma Sakhe is hailed as one of the best primary care health care approaches and is supposed to act as the model on which all other provinces will base their systems.

There is a lot of work to be done in terms of supporting the people who drive the operation. For many people in far-flung rural areas, CCGs are their only line of connection to the public health care system and to social services.

It is not enough to theoretically empower CCGs without providing necessary resources for them to carry out their work.