A year after a clinic monitoring report highlighted challenges in Mpumalanga clinics, some patients say they sometimes spend more than four hours waiting to be seen at these facilities and suffer abuse at the hands of healthcare workers.

The community-led clinic monitoring project Ritshidze last week released its follow-up report on the state of (primary) healthcare in Mpumalanga.

While there has been an improvement in waiting times, which fell from 4.33 hours to 4.05 hours over the past year, this “remains an extremely long time for public healthcare users to wait at the facility to only be seen for a limited time,” the report states. There is also a concern that “having people living with HIV spend an extended time at a facility, simply to collect ART [antiretroviral therapy] refills, also increases the risk of that person disengaging from care”.

Out of the 1,833 public healthcare users interviewed, the majority said that waiting times at clinics in Mpumalanga are long. Some of the reasons for the long waiting times are messy or lost files (37%), staff shortages (31%), and staff not working or dragging their feet (31%).

Healthcare users relayed their experiences to clinic monitors.

“I go to Khumbula Clinic. They don’t treat us well. We arrive early in the morning and leave late, around 2pm. I no longer collect my treatment. I want to go back but because of the mistreatment there, I stopped going. They see me as a nobody,” says one healthcare user.

“It hurts to feel less important in the community or clinic, because we spend the whole day moving from one bench to another, only to be told that they cannot help you. You don’t even have money to buy an orange. You are hungry and spend the whole day there,” says another healthcare user.

Data for the report were collected between April and May 2022 and 42 facilities were monitored.

Some improvement 

Last year, Ritshidze reported that only 7% of facility managers at clinics in Mpumalanga said they had enough staff. In this year’s report, the number increased to 41%. While certain improvements have been made, there is still a human resources gap, the report states. This year, 54% of public healthcare users said there are always enough staff (up from only 30% last year).

Patients in a waiting room at Lebogang community health centre in Mpumalanga. (Photo: Rian Horn / Ritshidze / Spotlight)

The report also shows that there is a surge in the number of unfilled vacancies across facilities monitored in the previous year. Although the department has started to fill these vacancies, there are still 97 vacancies across 17 sites. The most commonly reported vacancies are for enrolled nurses, professional nurses and doctors.

“The Mpumalanga Department of Health committed last year to fill all vacancies and prioritise 476 critical posts for the 2021/22 financial year, which were to be advertised and filled in different phases of that financial year,” the report states. 

“While there have been positive improvements across facilities monitored in the province, a clear gap still remains between the staffing needed to ensure high-quality services and the staff present each day at site level.”

Last year, 74% of the facilities that Ritshidze monitored had filing systems that were in a bad state. This year, that number dropped to 38%. Among the facilities that need to improve their filing systems are Amsterdam CHC, Bethal Town Clinic, Embalenhle CHC and Ermelo Clinic. Files that are orderly and readily available are crucial in keeping waiting times low.

One patient says that sometimes when they arrive, patients are told: “‘Your file is missing,’ and they say you must start a new one.” He says the new files do not contain the patient’s history. 

“I take treatment at a clinic in Extension 14. I have never seen my file. They only issued papers even when I do blood tests [and] they never explain the results. When I moved to a private pharmacy to collect my treatment they didn’t explain what time I should take my pills,” says the patient.

Low satisfaction rates

According to Ritshidze, Mpumalanga has been flagged as a particularly concerning province as its public healthcare facilities had the lowest satisfaction rates among interviewees.

The DA’s health spokesperson in the province, Jane Sithole, says clinics and community healthcare centres are barely functioning due to long overdue maintenance ranging from dysfunctional geysers and leaking roofs to broken water pumps, which forced nurses to collect water in buckets to clean clinics.

“Communities are continuously complaining that the healthcare workers are in the wrong or not doing their jobs. What the communities don’t know is that it is not their fault, but it’s actually the MEC and the officials in the department who are failing to deliver on the basics to ensure clinics have things such as medicine and rotational doctors.”  

Sithole says departmental health officials don’t have to face patients and their families, but it is healthcare workers who must deal with angry family members and it is understandable why healthcare workers are negative at times towards patients.

According to the report, 26% of facilities monitored were in a bad condition last year, 89% of facilities needed additional space, 40% of facilities did not have enough room in the waiting area and 58% of facility toilets were in bad condition. This year, Ritshidze recorded the same number — 26% — of facilities that are still in a bad condition, while more facilities (58%) did not have enough room in the waiting area.

The department responds

Responding to questions on staffing, Mpumalanga health spokesperson Dumisani Malamule says the department is employing more nurses to reduce long waiting hours at clinics. He says the Buffelspruit Clinic is, however, experiencing long waiting hours due to the fact that the clinic is undergoing renovations and a mobile clinic has been set up to render services.

“Posts are being advertised every now and then and filled accordingly. We also have Mpumalanga Nursing College, where more than 500 nurses graduate every year and they are placed in clinics around the province.” 

The filing system at Ermelo Town Clinic in Mpumalanga. (Photo: Rian Horn / Ritshidze / Spotlight)

Malamule says the department absorbs all these graduates, but the DA says many doctors and nurses prefer to work in the more urban provinces, such as Gauteng. 

Regarding poor staff attitudes flagged in the report, Malamule says: “Training on customer care is being provided to our staff members. The department also monitors their behaviour and always encourages patients to report any misbehaviour by staff as soon as possible. Strict disciplinary action is also being taken against those that do not comply with patient care.”   

A huge chunk — R10-billion — of the Mpumalanga Department of Health’s R16-billion budget for this financial year has been allocated to district health services, which clinics fall under. While tabling the 2022/2023 budget, Health MEC Sasekani Manzini said her department was determined to increase access to health services. This, she said, is done through deploying mobile clinics to augment the 292 primary healthcare facilities, particularly in remote and rural areas. The department has 92 mobile clinics with 2,186 points that service these remote areas, she said.

“There is still a need for 65 additional mobile clinics to replace and add to the current fleet. However, due to budgetary constraints, the department has prioritised procurement of 17 mobile clinics in the 2022/23 financial year to assist in sustaining the service, with an estimated cost for the additional mobile clinics [of] R19-million,” Manzini said.

She said her department has received requests to increase the operating hours of clinics to 24 hours a day.

But Manzini said she had not yet granted permission for the increase of hours of any facilities in line with the national norms and standards, which provide clear directives on the categories of health establishments taking into account population distribution.

According to the Ritshidze report, “None of the non-24-hour facilities are reported as opening by 5am on weekdays and only two non-24-hour facilities were reported as opening by 8am on Saturdays”.

Manzini said she was “fully aware that some of these clinics’ infrastructure struggle to meet the demand of the community.

“In recent years, we have observed a high rate of mushrooming communities that demand to have fixed structures even if they do not qualify to have one due to population size. These pose a challenge for us because most of the new areas are highly scattered.” 

She said the department had developed an infrastructure plan “on envisaged construction of health facilities in areas that do not have fixed structures.  The department has also developed a five-year Provincial Infrastructure Improvement and Maintenance Plan that is aligned to the Ideal Clinic initiative informed by district plans.”  

Manzini said the budget for maintenance and improvement of infrastructure was not enough as R10-million had been put aside for clinics earmarked to be Ideal Clinics.

Towards fixing primary healthcare

Professor Helen Schneider, a public health specialist and health system policy researcher, says ensuring that there is competent leadership in the sector is important to maintain stability and deliver services to communities.

The complaints and suggestion box at Ermelo Town Clinic in Mpumalanga. (Photo: Rian Horn / Ritshidze / Spotlight)

“Government should ensure that those who are in leadership positions are equipped with the necessary skills and knowledge. It is important that there is a culture shift where patients and healthcare workers are put first,” says Schneider.

She says that further political initiative is required for resources in the health sector to be used properly. 

“It is gratifying to see that there were improvements recorded, although we are far away from achieving a people-centred health system. Independent citizen scorecards can achieve the desired change and initiatives such as Ritshidze will help to improve the health system,” says Schneider. 

Russell Rensburg, the director of the Rural Health Advocacy Project, says it is important to invest in rural healthcare because rural areas are  where most of the people who require medical attention reside but the healthcare systems in these areas are weak.

“It is important to deploy community healthcare workers in rural areas to ensure that people can access health services like testing and access to chronic medication.”  

Rensburg says most people in rural areas do not have the correct information on which health services they can access and where they are accessible, which creates a barrier to utilising the system to its full capacity. 

“It is equally important for health departments to ensure that they conduct regular surveys to see where their shortfalls lie,” he says. DM/MC

This article was published by Spotlight – health journalism in the public interest.