The family of Zenizole Vena, who died last month in Gqeberha in the Eastern Cape, blames the staff at Motherwell NU11 Clinic for the suffering their daughter endured in the final hours of her life.

Mziyanda Vena, a family member, tells Spotlight the 15-year-old was taken hostage on 17 September 2022 and gang-raped. She managed to escape five days later, when she was found by a resident roaming the streets and taken to the NU11 clinic in Motherwell.

There, Vena says, nurses turned her away, allegedly telling her to first report the rape at the police station. The resident who found Zenizole informed her grandmother, who stays near the clinic. She then came to take her to the police station.

Zenizole went to the Motherwell police station where she later died. The family says the police told them she had an epileptic seizure and they called an ambulance, but she died before it arrived. The family blames the police for not calling an ambulance sooner, saying this resulted in her death.

Mziyanda Vena accuses the clinic of negligence and says the provincial health department’s handling of the matter was disappointing.

“There is no way we can simply leave this issue unchallenged. We will take it further in the interests of others who may also face the same treatment in future at the hands of healthcare staff,” he says.

According to Eastern Cape Health Department spokesperson, Yonela Dekeda, the department is investigating the events that led up to Zenizole’s death.

Meanwhile, Eastern Cape Premier Oscar Mabuyane has reportedly asked the Health Ombud to investigate. However, Ricardo Mahlakanya, Health Ombud spokesperson, told Spotlight they had not received any complaint in this case.

Staff attitudes

Poor staff attitudes and patients complaining of being treated badly by healthcare workers at some clinics in the Eastern Cape were also among the issues flagged in the latest report by community-led clinic monitoring group, Ritshidze. They noted similar complaints in last year’s report.

Ritshidze launched its second Eastern Cape report on 13 October in Mdantsane, East London. Data was collected from 2,478 public healthcare users — about half (51%) were people living with HIV. Respondents included drug users, sex workers, and LGBTQIA+ communities.

Ritshidze’s report flags staff attitudes at some clinics in the Eastern Cape as a problem. (Photo: Rian Horn / Ritshidze / Spotlight)

Although the findings show some improvement, there are clinics that — compared with last year — performed worse on some indicators. For example, last year 63% of respondents indicated that they received friendly and welcoming services, but this year the figure was 55%.

Motherwell NU11, where the tragedy involving Zenizole Vena took place, was not among the 49 healthcare facilities monitored in the province between July and August this year.

Room for improvement

Responding to the Vena case, Dekeda says there was room for improvement in the way the patient was referred to the police.

“The preliminary report indicates that the girl was attended to at the NU11 clinic and was found to be clinically stable. She was referred to the police for the incident to be reported and thereafter for related processes to be followed. The department will deal with any shortcomings identified during our investigation and appropriate action will be taken. This includes taking appropriate disciplinary action where recommended,” Dekeda says.

“The post-mortem into the cause of death has been undertaken and the findings have been explained to the family. For confidentiality reasons, this cannot be disclosed to the public at this time. The department has also been engaging with community representatives to find an amicable solution to the impasse. 

“When someone has been raped, the incident must be reported to the police first, then the case number with the associated rape kit is issued for the victim,” says Dekeda.

Hundreds of eople interviewed by Ritshidze in the last year reported having been denied access to services for not having a transfer letter across 40 facilities. (Photo: Rian Horn / Ritshidze / Spotlight)

“The patient is then taken to the nearest Thuthuzela Centre with the rape kit. This kit contains the necessary legal paperwork that the medical team needs to complete, and swabs and collection bags for items of clothing and specimens that are collected.”

However, in response to a question in Parliament by DA MP Samantha Graham, Health Minister Dr Joe Phaahla said in June last year that “hospitals are not precluded from processing a rape survivor if that person has not given a statement at a police station first. 

“Survivors of rape have a choice of which authority they wish to access first. We, however, have noted that the majority of rape survivors access the health facility first before they report the matter to a police station and are not dismissed at all.”

Fear of being ill-treated

In the Ritshidze report, many people living with HIV — and those from key populations (men who have sex with men, drug users, transgendered persons, and sex workers) — reported being treated badly by clinic staff. 

Ritshidze’s data shows that only 27% of people living with HIV who missed previous appointments, were welcomed when they returned, while 14% of respondents reported being shouted at by staff. The report notes that people are discouraged from visiting some clinics for fear of being ill-treated.

Due to poor staff attitudes, 47% of gay, bisexual and other men who have sex with men, 41% of drug users, 39% of sex workers, and 47% of transgender people have given up on using the public healthcare system, according to the report. 

Healthcare users wait at Philani clinic. (Photo: Rian Horn / Ritshidze / Spotlight)

“For key populations,” the report notes, “clinic visits can be traumatic and staff can be unfriendly and even openly hostile.”

The report highlights how people — especially those living with HIV and from key populations — are treated at health facilities is critical in ensuring treatment adherence or preventing them from disengaging from care.

Some healthcare users also report being refused access to services for not having documentation such as an identity document or transfer letter from another facility — contrary to national policy: “… 403 people interviewed by Ritshidze in the last year reported having been denied access to services for not having a transfer letter across 40 facilities, with a huge number of reports in the last reporting period.

“It is important to note that Ritshidze interviews take place at the facility. Therefore, people who have already disengaged from care due to challenges accessing a transfer letter would not be at the facility to interview.”

Among Ritshidze’s recommendations to curb reports of ill-treatment is for “all staff to be trained and held accountable to provide a friendly and welcoming environment for all public healthcare users, including key populations and people living with HIV returning to care after a late/missed scheduled visit, silent transfer from another facility, or treatment interruption”.

Reports of poor staff attitudes must urgently be investigated and consequences should follow where appropriate, they recommend.

Some progress

This year’s report shows that progress has been made in supporting people living with HIV to stay on treatment, according to Ndiphiwe Bekwaphi, a Ritshidze district organiser from the Treatment Action Campaign (TAC).

“More people living with HIV reported three- to six-month refills this year — up from 20% to 40%. The number remains very low compared with other Pepfar-supported countries where 80% of people living with HIV received three- to six-month ART refills in 2021.

“There has also been an improvement in treatment literacy in the last year, as 91% of HIV-positive patients reported that their healthcare provider explained the results of their viral load test to them, up from 79% a year ago.

Not only staff attitudes, but also the conditions at some clinics are flagged as a concern. Issues such as toilets not working and the cleanliness of some facilities are highlighted in the report. (Photo: Rian Horn / Ritshidze / Spotlight)

“This correlates to 89% of HIV-infected individuals understanding that an undetectable viral load is beneficial to their health, up from 72% last year,” says Bekwaphi, “and 85% understanding that they can’t transmit HIV when they have an undetectable viral load (up from 67% last year). It is imperative that these messages continue to be communicated to all people living with HIV.”

The report shows that average waiting times have improved since last year, from four hours and 37 minutes to three hours and 47 minutes. Despite this, 60% of healthcare users interviewed still complain about long waiting times. Most of them (66%) blamed the long waiting times on staff shortages.

Of the facility managers Ritshidze interviewed, 14% said they have enough staff, compared with 11% last year. They said it remains a challenge to recruit and retain healthcare workers in rural areas, with 30 facilities reporting 322 vacancies this year. Among the most understaffed categories were professional nurses.

Worst and best performing

Interestingly, a response by Minister Phaahla to another parliamentary question regarding poor- and best-performing (health) districts in the country shows that not one district in the Eastern Cape is among the top 20 in the country. The Health Department uses the Ideal Clinic Framework’s indicators to assess each district’s performance, said Phaahla.

“The reason for using this framework,” reads his response, “is because it covers aspects of services that districts should provide to persons in the community setting, in private healthcare facilities to the level of referral to higher level care if needed. 

“The Framework is a comprehensive evaluation measure, and its elements cover administrative processes, aspects of clinical care, medicines supplies, access to laboratory tests, human resources, finance, security, cleanliness, referral, transport, EMS, infrastructure, health information management, internal communication, external communication, governance and intersectoral collaboration.”

In many respects, the department’s list of worst-performing districts in the Eastern Cape mirrors that of the clinics in districts Ritshidze monitored. For example, the worst-performing district in the Eastern Cape is Oliver Tambo, with only 7% of clinics having reached ideal status.

Oliver Tambo District is followed by Alfred Nzo with only 9% and Joe Qabi with 19% of their clinics having reached ideal status. Among the province’s districts, Nelson Mandela Bay metro had the highest score with 77% of its clinics, and Sarah Baartman was second-highest in the province, but with only 39% of its clinics with ideal status.

Department ‘encouraged’ by improvements

According to Dekeda, the Ritshidze report has been presented to the extended top management of the department after the MEC received it for consideration of recommendations.

“We are encouraged by the measurable improvements described in the report, as this shows our quality improvement initiatives are having the desired impact on the quality of care our patients receive at clinics in the province,” says Dekeda.

“Although there are areas for improvement, this report helps us monitor the impact of our service improvement initiatives each year. It also helps us focus our efforts in the future on specific areas.”

The waiting game. Queues at Mthatha Gateway Clinic. (Photo: Mandisa Ndinisa / Ritshidze / Spotlight)

She said some of the challenges outlined in the report, such as staff attitudes and waiting times, are being addressed.

“We have really had a difficult time with the pandemic and the (Covid) response has really put a strain on our staff.”

Dekeda says the department’s Annual Recruitment Plan (ARP) approved 2,941 posts for the 2022/23 budget with an allocation of R700-million.

“We have already implemented more than half of the ARP. A further R1.5-billion has also been set aside for infrastructure projects. Regarding the shortage of medication, the department is also using Stock Visibility Solution to monitor the available stock in health facilities,” she says. DM/MC

Note: A member of the TAC is quoted in this article. Spotlight is published by SECTION27 and the TAC, but is editorially independent, an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

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