Inside the Right To Care Aids clinic in Johannesburg on 27 January 2012. The Right to Care NGO had, with Pepfar funding, managed to revive its Alexandra Aids clinic. (Photo: Gallo Images / Foto24 / Cornel van Heerden) 
In the wake of this year’s US President’s Emergency Plan for Aids Relief (Pepfar) funding cuts, community-led monitoring group Ritshidze has continued to track service delivery at state healthcare facilities in the Free State, Limpopo and Mpumalanga’s Ehlanzeni district.
Ritshidze falls under the Treatment Action Campaign (TAC), an HIV/Aids activist organisation, and has been monitoring the state of primary healthcare since 2018 through surveys and interviews with patients and providers. Its recent reports are based on data collected between April and June 2025, shortly after the Pepfar cuts.
The groups noted that data collected from 326 public health facilities in 16 districts across six provinces showed a “system-wide slide in the basics” after the Pepfar cuts.
Free State in a poor state
In the Free State, 84% of health facilities surveyed said there were too few staff. Among those clinics that provided reasons for staff shortages, 40% said there were one or more vacancies at the facility, 25% said there were not enough positions and 10% said staff from the Pepfar implementing partner were no longer working or were working at a reduced capacity.
Read more: Ritshidze monitoring unmasks severe service slide in Gauteng, KZN, and Eastern Cape post-Pepfar cuts
Ritshidze collected clinic-level data at 57 public health facilities in three districts: Lejweleputswa (17 sites), Mangaung (20) and Thabo Mofutsanyana (20).
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“The Free State had the longest waiting times out of all provinces monitored by Ritshidze, at 5.25 hours – with Mangaung close to seven hours. Long waiting times continue to frustrate public healthcare users who waste long hours in queues for check-ups and even just to collect medication,” Ritshidze’s report reads.
Most patients blamed the long waiting times on staff shortages, or the poor state of filing systems and how long it took to locate files.
Of the facilities monitored by Ritshidze, 44% noted that their filing systems were in “bad condition”, up from 38% in January 2025. The situation was reportedly dire in Mangaung, where 80% of filing systems were in a bad condition.
“Delays can be worsened by disorganised paper filing systems. This can be the result of overburdened staff working in a rushed manner, no dedicated filing room staff, or small filing rooms without the space needed to organise properly,” the report says.
Only 9% of facilities said there were fewer or no staff to perform HIV viral load tests after the Pepfar cuts.
Free State health department spokesperson Mondli Mvambi told Daily Maverick the department “frequently” filled vacancies when there were openings.
Regarding long waiting times, the department was “embarking on various strategies to decant patients that are on chronic medications but stable".
“The department has moved from two months, three months, four months and now [to] six multi-month dispensing of medication.”
Mvambi said the department was in the process of digitising filing systems for “ease of storage and retrieval”. There had been a move towards an electronic patient registration system, which was successfully piloted for the entire country, in Dihlabeng and Lejweleputswa.
“The report is not of Ritshidze – it is jointly prepared with the Department [of Health] and an action plan is being developed thereafter to see what can be done for who, where, when, why, with what and how,” Mvambi added.
“The impression must never be created that the department is only responsive when Ritshidze is there because we work on these issues which are context-bound and informed by migration patterns of both patients and staff, resources availability from national allocations, provincial revenue and donor funding, availability of skills and availability of resources for infrastructure upgrades and purchase, servicing and maintenance of equipment.”
Mvambi added that the Free State health department had successfully delivered services across critical areas, including upgrading infrastructure at a number of hospitals and completing new clinics, appointing 483 student nurses this year and registering 3.8 million patients in the Health Patient Registration System.
Limpopo staffing woes
In Limpopo, 80% of facilities surveyed reported too few staff, with the primary reasons being one or more vacancies at the facility, too few positions and staff from the Pepfar implementing partner no longer working or working at a reduced capacity at the clinic.
Data was collected at 60 public health clinics in three districts: Capricorn (20 sites), Mopani (20) and Vhembe (20).
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Limpopo had the fifth-longest waiting times out of the six monitored provinces.
“Capricorn has the third-longest waiting times out of all districts monitored by Ritshidze at 4.33 hours – and 17% of people in the district said waiting times had worsened following the Pepfar withdrawal,” Ritshidze says.
Most of the patients surveyed blamed the long waiting times on staff shortages or slow-working staff.
Only 7% of the monitored facilities reported that their filing systems were in bad condition.
“Filing systems were observed to be in a good condition in 93% of sites monitored in the province – 95% in Capricorn, 95% in Mopani and 89% in Vhembe.”
The report showed that only 4% of sites reported fewer or no staff to conduct HIV viral load testing after the Pepfar cuts.
Daily Maverick asked the Limpopo health department for comment but had not received a response by the time of publishing.
Ehlanzeni district, Mpumalanga
Ritshidze monitoring at 20 sites in the Ehlanzeni district of Mpumalanga showed that after the Pepfar cuts, just 76% of patients surveyed reported that healthcare workers explained the results of their viral load tests to them, down from 82% in January 2025.
The monitoring group raised concerns about declining treatment literacy in the region.
Of the facilities surveyed, 80% reported staff shortages, with most blaming this on the insufficient number of positions at the clinics, as well as staff from the Pepfar implementing partner no longer working or working at a reduced capacity.
There were 19 vacancies reported across the sites, with data capturers and nursing cadres the most understaffed.
“Evidence on human resources shortages must be used to inform plans for use of the additional funds provided by Treasury. Counsellors are critical and must be prioritised,” Ritshidze says.
There were increases in waiting times in Ehlanzeni after the Pepfar cuts, with 16% of public healthcare users indicating that delays were longer than usual.
Filing systems were reported to be in bad condition at 30% of sites monitored across the district.
Karabo Nkosi, spokesperson for the Mpumalanga health department, said the department was aware of Ritshidze’s report.
“What we know is that all our health professionals are trained in HIV clinical management, which includes explaining various test results for HIV clients. Furthermore, the department has HIV counsellors who are trained and, as part of counselling, monitor and explain viral load results to clients,” she said.
Nkosi said that at the time of Pepfar’s withdrawal, the US programme was “no longer involved with the management of HIV clients, except providing technical support”.
The department has entered into a service-level agreement with the nonprofit Right to Care to appoint and place clinical and non-clinical staff across the region, she continued. These included 49 professional and enrolled nurses placed at Ehlanzeni facilities, and 146 data capturers, four HIV and TB specialists and 18 pharmacists and pharmacist assistants appointed throughout the province.
“The department is using an electronic system called TIER.NET for HIV client information. This system supplements the manual record keeping system,” Nkosi added. DM