Working for access to quality public healthcare in South Africa since 1998
2 November 2017

Detailed report on state of Limpopo Health System

POLOKWANE, 2nd NOVEMBER 2017 – The Treatment Action Campaign (TAC) in Limpopo has released a detailed and comprehensive report today on the state of healthcare in the province. This will be delivered to MEC of Health Dr Phophi Ramathuba as 500 TAC members march to her offices in Polokwane. 

“TAC is marching today because the health system in Limpopo is broken. It is on life support and in critical need of resuscitation. Each day we hear reports of collapse, pain, indignity, loss, shock and grief. Our peoples’ Constitutional right to healthcare is being violated,” says Helen Nkuna TAC Limpopo Chairperson.

“We have received numerous complaints and reports of systems failure which has dire consequences for patients.  Our own monitoring in recent months at facilities across the Mopani and Vhembe districts confirm the extent of this crisis. If the MEC does not take our demands seriously, we will be back here in our numbers.”

We outline the full report below. 

#LimpopoHealthCrisis

For more information and to arrange interviews contact:

Lotti Rutter | lotti.rutter@tac.org.za | 072 225 9675

Dear Honourable MEC Ramathuba,

The Treatment Action Campaign (TAC) in Limpopo represents users of the public healthcare system and campaigns on critical issues related to the quality of and access to healthcare. The organisation currently has a network of 24 branches in the Mopani and Vhembe districts in the province. Through these branches we monitor service delivery at a number of clinics and hospitals. Our members are the people who need the public health system to work, so they are the first to notice when it does not.

TAC Limpopo notes your appointment as Health MEC in the province. We applaud your efforts to turnaround the crisis of mismanagement and corruption in the Department of Health. However, much more needs to be done to ensure that everyone can access quality healthcare services. Many persistent challenges and failings are plaguing the public healthcare system that requires an urgent and comprehensive turnaround strategy. We outline these below. 

Background

The results of local facility monitoring by TAC branches during October 2017 across the Mopani and Vhembe districts highlights a number of critical concerns with regard to the state of primary healthcare in the province. A summary of the results of data collected is provided below. The full data set is captured in appendix 1.

In addition to monitoring facilities, TAC branches engage with members of the community to understand the challenges and collect testimonies and complaints that relate to these concerns. The table below outlines testimonies collected in the month of October 2017 and which broad issues these align to. 

Name of facility

Staff Attitude

Medicine shortages

Long waiting times

Bad services

Poor infrastructure

Lack of staff

Hlaniki Clinic

09

21

24

09

00

09

Marserselles Clinic

04

18

09

05

00

02

Vyeboom Clinic

17

25

33

09

50

33

Mukhomi  Clinic

06

29

36

07

26

40

Tlangelani Clinic

10

16

22

08

00

12

Malamulele Hospital

08

24

14

02

00

06

Mapayeni  Clinic

12

13

25

08

28

18

Dzumeri Health Centre

16

29

25

19

00

10

Giyani Health Centre

00

04

07

00

00

00

Lulekani Health Centre

34

30

36

21

09

15

Khakhala Hlomela Clinic

10

33

37

05

00

20

Dr Hugo Clinic

08

12

10

09

06

27

Grace Mugodweni Health Centre

15

23

38

15

09

08

Shayandhima Clinic

07

19

09

07

00

05

Nkensani Hospital

34

43

24

20

05

16

Ratanang Clinic

18

19

28

05

00

07

Shivulani Clinic

25

26

30

10

00

03

Nkuri Clinic

06

18

20

09

29

17

Mariveni Clinic

10

22

12

06

02

01

Khujwani Clinic

26

35

40

20

07

20

Mohlaba Clinic

16

19

13

10

09

09

Mpheni Clinic

15

14

10

08

00

03

Waterfall Clinic

10

23

17

18

05

00

Elim Hospital

23

32

28

20

18

08

Total: 24

Total:339

Total:547

Total:547

Total:250

Total:203

Total:312

 

We have also conducted a fact finding mission in eight hospitals in the province, the results of which are shared below.

The data collected by our branches corresponds to the worrying picture of our public healthcare system painted by reports published earlier this year by the Office of Health Standards Compliance.

Key concerns and demands

Please note: The deadline for meeting a number of the below demands is end November. Failure to meet all these demands by the set date will result in a stepping up of our advocacy activities – which may include sit-ins, protest action, and various forms of civil disobedience.

  1. Critical human resource shortages

The shortage of human resources is a major issue in Limpopo. Ensuring access to quality healthcare services and ensuring everyone living with HIV and TB get access to treatment and care depends largely on having enough qualified and committed staff – including doctors, nurses, pharmacists, pharmacy assistants, community healthcare workers (CHWs), lay counsellors, peer-educators, and security guards, porters and cleaners. 

However, instead of filling vacant posts and ensuring that there are enough people to properly deliver our healthcare, posts are being frozen in many areas. While many doctors and nurses remain unemployed, there are not enough open positions to employ them. The problem is only exacerbated for rural communities who struggle to attract specialists and senior doctors. According to the National Department of Health, there are currently over 44 000 funded posts in Limpopo. Of these only 35 450 are filled leaving almost 10 000 vacant posts in the province. This translates into almost 25% of the workforce. An HSRC report showed the vacancy rate of doctors at 75% – and nurses at 67%.

These shortages lead to long waiting times, longer hospital stays, higher numbers of deaths, and increased pressure on the few staff in place. One of the major causes of medicine stockouts and shortages are a result of staff being too busy to place orders in time.

Long waiting times due to a shortage of staff to adequately deliver healthcare was the most prominent issue found in a fact-finding mission in several hospitals in the province this week.

  • In Malamulele Hospital people queued that day from 5.30am. Security began at 7am. Within the Hospital around 200 people were waiting to be attended by two doctors;
  • In Tshilidzini Hospital around 75 patients were waiting for files. Those we spoke to had been waiting for files for over five hours. Once files were found patients entered the next phase of waiting to be attended to;
  • In Elim Hospital patients waited for files for around 5 hours. After collecting files they entered the queue to be attended to. In a corridor around 100 metres long, patients filled the entire hall waiting to be seen. One man had been admitted six hours prior but still remained on a trolley in the corridor.
  • In Nkhensani Hospital, patients had been queuing since 5am. While they had received files they were still waiting for a doctor to arrive at 10am.
  • In Van Velden Hospital patients had been waiting more than five hours to be seen. They sat patiently whilst the doctors went on lunchbreak.

According to the South African Medical Association (SAMA) in the province:

  • Pietersburg Hospital continues to exist with only one operating theatre on weekends, public holidays and afterhours due to understaffing of nursing personnel in the hospital. This has resulted in patients not being operated timeously and ultimately resulting in morbidity and in worst-case scenarios, mortality.
  • Nkhensani Hospital continues to struggle without both a Senior Clinical Manager and a Chief Executive Officer, leaving the hospital rudderless.
  • Medical practitioners continue to go beyond their contractual overtime without compensation in hospitals such as W.F Knobel, Seshego, Nkhensani and Donald Frazer. This leads to frustrations within the workforce and manifests in a worsening of staff attitudes – ultimately affecting patients seeking services.

As per monitoring at local primary health facilities, staff shortages and long waiting times were a major challenge. 17 out of 21 facilities surveyed did not have enough staff, with only 1 out of 21 facilities having waiting times of less than 30 minutes.

Our demands:

  1. We demand the release of the provinces Human Resources for Health (HRH) plan before end November this year. This plan should include a comprehensive list of current vacancies.
  2. We demand that all vacant posts be filled in the next financial year and that the employment of nurses and doctors is prioritised in the 2018/19 financial year.

 

  1. Poor infrastructure and a lack of equipment in facilities

Health facilities infrastructure in Limpopo is often aged and run down, dysfunctional or inappropriate to the needs of patients. Most of the facilities outside the NHI pilot district area were built in the early 90s with little renovation. During a fact finding mission this week we found:

  • At Malamulele Hospital there has been no constant water supply for the past three years. Patients are unable to wash and there is a small amount of container water for using the toilets. Laundry is outsourced to Polokwane Hospital. Linen was seen to be dirty. Furthermore, patients have no privacy in the wards with no doors or curtains in place.
  • At Tshilidzini and Nkhensani Hospitals there is no waiting area for visitors. People wait in the grounds for visiting hours to begin.

The following 17 facilities are noted as needing urgent renovation. These structures are either aged, broken, or too small to ensure quality healthcare services:

  • Mapayeni Clinic
  • Thomo Clinic
  • Vyeboom Clinic
  • Khakhala Hlomela Clinic
  • Nkuri Clinic
  • DzumeriHealth Centre
  • Zava Clinic
  • Hlaneki Clinic
  • Malamulele Hospital
  • Manavela Clinic
  • Tshino Clinic
  • Tshimbupfe Clinic
  • Davana Clinic
  • Tshilidzini Hospital
  • CN Mpathudi Hospital
  • Dan Clinic
  • Elim Hospital.

According to the South African Medical Association (SAMA) in the province:

  • The procurement of basic equipment (i.e. Casualty ventilators, ABG machines, anaesthetic machines & many others) moves at a slow pace which leads to rising morbidity and mortality from preventable conditions in regional hospitals. In addition, regional hospitals continue to exist without functional high care units.
  • Tshilidzini hospital, which takes care of the whole of Vhembe district has to function with no high care and an ICU that has only four beds.
  • While new equipment has been delivered at both Pietersburg and Mankweng Hospital, more must be done to prevent morbidity and mortality.

Our demands:

  1. We demand an urgent, fully-funded, plan to address infrastructural issues at the 17 facilities identified above. We demand to see this plan before the end of November this year. We expect the MEC and the Premier to make this a priority and to ensure the funds are made available.

 

  1. TB infection control measures at all public health facilities

In the run up to World Tuberculosis (TB) Day, TAC Limpopo assessed the state of TB infection control in a number of public health facilities across the province. Of 23 facilities assessed, 17 were found to be in a “RED” state with very poor infection control measures in place. 5 were found to be in an “ORANGE” state, and only one in a “GREEN” state with good TB infection control measures in place.

TB remains the leading reported cause of death with over 33 063 deaths in the country in 2015 according to a recent Statistics South Africa report. The rate of new cases of active TB in South Africa remains extremely high at around 450 000 per year. TB can be spread through the air when people with active TB disease cough or sneeze. However, various infection control measures can be taken to reduce the risk of TB transmission.

The following questions were answered by TAC members from local branches linked to each facility assessed:
 
1.     Are the windows open?
2.     Is there enough room in the waiting area?
3.     Are there posters telling you to cover your mouth when coughing or sneezing?
4.     Are you seen within 30 minutes of arriving at the clinic?
5.     Are people in the clinic waiting area asked if they have TB symptoms?
6.     Are people who are coughing separated from those who are not?
7.     Are people who cough a lot or who may have TB given tissues or TB masks?
 
Based on the answers to these seven questions facilities were ranked RED (3+ questions answered “no”), ORANGE (1-2 questions answered “no”), or GREEN (0 questions answered “no”). The facilities scored as follows:

Facility

District

Rating

Basani Clinic

Mopani

RED

Davhana Clinic

Vhembe

RED

Dzumeri Health Centre

Mopani

RED

Giyani Health Centre

Mopani

ORANGE

Humulani Clinic

Mopani

ORANGE

Khakhala Hlomela Clinic

Mopani

ORANGE

Khujwana Clinic

Mopani

RED

Lulekani Clinic

Mopani

RED

Manavhela Clinic

Vhembe

RED

Marseilles Clinic

Vhembe

RED

Mukhoni Clinic

Vhembe

RED

Nhlaneki Clinic

Mopani

RED

Nkensani Gateway Clinic

Mopani

GREEN

Nkowankowa Clinic

Mopani

RED

Ratanang Clinic

Mopani

ORANGE

Sekhimini Clinic

Mopani

RED

Shayandima Clinic

Vhembe

RED

Shivulani Clinic

Mopani

ORANGE

Thomo Clinic

Mopani

RED

Tshimbhupfe Clinic

Vhembe

RED

Vyeboom Clinic

Vhembe

RED

Waterval Clinic

Vhembe

RED

Zava Clinic

Mopani

RED

We commend Nkhensani Gateway Clinic, the only GREEN facility. This should be the status quo. The problems highlighted in TB infection control through the audit are indicative of the wider crisis within the Limpopo health system, where overstretched nurses at understaffed clinics lack the capacity and resources to engage effectively in TB infection control measures.

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

Our demands

  1. We demand that the Limpopo Department of Health carries out a full audit of all public health facilities in the province to assess whether sufficient TB infection control measures are in place.
  2. We demand that masks and TB posters are distributed to all facilities by end November this year. Spot-checks should be undertaken to ensure these are utilised.
  3. We further demand that by end November this year a circular is sent to all facilities to ensure that all patients are triaged to ensure those with TB symptoms are seen first to avoid the risk of transmitting to other patients.
  4. Finally, where infrastructural issues mean that public facilities are too small creating a TB risk factor, a turnaround strategy must be developed to outline how this will be rectified by end of February 2018.

 

  1. Adequate stock of medicines and other medical supplies including HIV and malaria testing kits

Stockouts of essential medicines places the health of TAC members and people in our communities at risk. TAC is committed to continuing to monitor stockouts and advocating for systemic solutions to stockouts. While stockouts and shortages of ARVs have mostly been addressed because of the interventions of TAC and the Stop Stockout Projects, medicines for malaria, diabetes, high blood pressure, paediatric medicines, and many other conditions, are regularly out of stock or in short supply. The local facility survey showed that in October 9 out of 21 facilities surveyed were facing a stockout or shortage of medicines and patients were sent home empty handed.  

In relation to HIV testing, widespread stockouts and shortages of HIV testing kits were identified by TAC Limpopo in July 2017, following many complaints by members of the public. However since July the problem is only being addressed very slowly.

The HIV response depends on the ability of people to know their HIV status – and if found to be living with HIV, to immediately access antiretroviral therapy (ARVs). The evidence is clear that all people living with HIV should be initiated onto treatment as soon as they find out their HIV status. This not only improves their long term health, but also limits the chance of spreading the virus to other people.

Initially, TAC attempted to resolve these challenges at a district level. The response of Mopani District Department of Health was that this is a national crisis. Vhembe District Department of Health stated that they had received no new stock, and were managing the crisis with limited stock rotations between healthcare facilities. As well as engaging with the District Departments to begin with, we also raised this matter directly with the MEC’s office and the HAST Manager.

The response was that a new tender had begun and new test kits were being dispatched. It was stated that the initial test is now the Abon test which was reportedly available. The confirmatory test is the 1st Response test of which there was limited supply. However, our own monitoring of the situation showed that both tests were in short supply. While the situation has been rectified in certain clinics, a spot check on 1st November shows that stock is limited in certain facilities and there is no stock in Ratanang Clinic and Vyeboom Clinic.

The fact that certain facilities have not had access to HIV testing kits for long periods in recent months is unacceptable. The lives and health of people with undiagnosed HIV are at risk because of this mismanagement.

Our demands:

  1. We demand an urgent provincial strategy to address the continued and ongoing stockouts and shortages of medicines and other medical tools and supplies – this plan must address the impact of human resource shortages and poor management where these impact on the ability of facilities to order supplies.
  2. We demand the resolution of the ongoing shortage of HIV testing kits in the province to ensure that all health facilities have access to sufficient quantities of kits by end November this year.

 

  1. Ensure all those in need are able to access appropriate and adequate mental healthcare services within the province

In terms of mental health, while the spotlight over the past few weeks has rightly been on Gauteng with regard to the Life Esidimeni tragedies, it is critical that the Limpopo Department of Health ensures that people’s dignity and right to access mental healthcare services is prioritised. The tragic and devastating loss of life in Gauteng cannot be allowed to happen again. Yet across South Africa, including Limpopo, mental health does not receive the recognition and attention it requires.

There are currently three psychiatric hospitals in Limpopo. However, the majority of users of these hospitals are not people with mental illnesses, but rather mostly people with learning and intellectual disabilities. These people should not be in these establishments however there are few other care or support services in the province. There are enormous waiting lists for Pfunanani Special School‎ for children with intellectual disability in Giyani. People with learning disabilities then end up institutionalised in these hospitals forever, despite not needing to be. This is deplorable. Furthermore, where people do get discharged, there is no halfway house to rehabilitate them. They are sent immediately back to their families without support.

One project in the Giyani area is under threat. Akaya is a psycho-social rehabilitation project that focuses on the personal development and economic empowerment of adults with intellectual and psychiatric disabilities. Their Halfway House accommodates mental healthcare users from the local mental health hospital to rehabilitate and capacitate them with relevant skills after discharge. However, the project is facing shut down due to challenges around water shortages and sewage problems that result in poor hygiene in the in infrastructure.

Our demands:

  1. We demand an immediate intervention at the Akaya psycho-social rehabilitation project with evidence of this intervention by end November this year.
  2. We demand that the province provides us with a detailed list of all mental health facilities in the province and a report on the human resource and infrastructural state of these facilities. We demand to see this report by end February 2018.
  3. We demand the development of specialist care centres that provide dignified care and support services to people with mental illness and learning disabilities.

 

  1. Access to prevention, treatment and care services for cancer

In terms of cancer and oncology Limpopo faces a number of challenges. At a recent dialogue on HPV, complaints were made to TAC that women faced extremely long waiting times to get the results of pap smears. Further they complained that nurses at a primary healthcare level lacked understanding on the prevention and diagnosis of cancers – and worse in certain facilities nurses demanded patients to only get pap smears in the mornings as they were not hygienic in the afternoon. In terms of treatment, while Polokwane Hospital provides certain chemotherapy, other forms of chemotherapy, radiotherapy and certain cancer treatments are not accessible within the province. Oncology patients are transported to Steve Biko Hospital in Pretoria.

In this regard we have the following questions of the Limpopo Department of Health:

  1. Are patients provided with planned patient transport to and from Steve Biko Hospital?
  2. Are patients provided with overnight sleeping facilities in the relevant Limpopo facility before and after transport to Steve Biko Hospital?
  3. Is there sufficient budget for chemotherapy and cancer treatments in the Department’s budget? How much is allocated to this?
  4. How many mammography machines are available in the province and in which facilities?
  5. Is there plans to provide training to nurses at a primary healthcare level to ensure better diagnosis of cancers?

 

  1. Functionality of clinic committees and hospital boards to ensure accountability at local and district levels

In South Africa, governance structures in the form of clinic committees and hospital boards are intended to ensure community participation at a local and district level. They are provided for in South African law and are key to ensuring accountability and a successful AIDS and TB response. They are the forums through which public healthcare users are meant to engage and take ownership over the health system, raise concerns and ensure accountability at local, district, and provincial levels. They should input and feedback into the planning, delivery and organisation of health services and play an oversight role in the development and implementation of health policies and provision of equitable health services. The committees are made up of a combination of community and civil society representatives and health professionals of each area. They allow community concerns to be elevated through the structures from local to district to provincial and finally to national level.

Section 42 of the National Health Act 61 of 2003 requires provinces to provide for clinic committees and hospital boards and ensure their functioning. However, to our knowledge Limpopo has not implemented this legislation – and it cannot be claimed that clinic committees or hospital boards function effectively across the province. Too many lack a clear understanding of their role and responsibility and no financial resources are allocated to improve this situation. TAC is attempting to capacitate certain clinic committees aiming to improve functionality to the benefit of public healthcare users, however TAC only works in 24 clinics across Limpopo. Of these 24, only 5 can be said to be functioning.

Our demands:

  1. We demand an audit report of the functionality of clinic committees and hospital boards by end February 2018.

 

For ease of reference we again list all our demands below:

1.a. We demand the release of the provinces Human Resources for Health (HRH) plan before end November this year. This plan should include a comprehensive list of current vacancies.

1.b. We demand that all vacant posts be filled in the next financial year and that the employment of nurses and doctors is prioritised in the 2018/19 financial year.

2.a. We demand an urgent, fully-funded, plan to address infrastructural issues at the 17 facilities identified above. We demand to see this plan before the end of November this year. We expect the MEC and the Premier to make this a priority and to ensure the funds are made available.

3.a. We demand that the Limpopo Department of Health carries out a full audit of all public health facilities in the province to assess whether sufficient TB infection control measures are in place.

3.b. We demand that masks and TB posters are distributed to all facilities by end November this year. Spot-checks should be undertaken to ensure these are utilised.

3.c. We further demand that by end November this year a circular is sent to all facilities to ensure that all patients are triaged to ensure those with TB symptoms are seen first to avoid the risk of transmitting to other patients.

3.d. Finally, where infrastructural issues mean that public facilities are too small creating a TB risk factor, a turnaround strategy must be developed to outline how this will be rectified by end of February 2018.

4.a. We demand an urgent provincial strategy to address the continued and ongoing stockouts and shortages of medicines and other medical tools and supplies – this plan must address the impact of human resource shortages and poor management where these impact on the ability of facilities to order supplies.

4.b. We demand the resolution of the ongoing shortage of HIV testing kits in the province to ensure that all health facilities have access to sufficient quantities of kits by end November this year.

5.a. We demand an immediate intervention at the Akaya psycho-social rehabilitation project with evidence of this intervention by end November this year.

5.b. We demand that the province provides us with a detailed list of all mental health facilities in the province and a report on the human resource and infrastructural state of these facilities. We demand to see this report by end February 2018.

5.c. We demand the development of specialist care centres that provide dignified care and support services to people with mental illness and learning disabilities.

6.a-e. We demand answers to the five cancer-related questions noted in section 6 above.

7.a. We demand an audit report of the functionality of clinic committees and hospital boards by end February 2018.

ENDS

 

For more information contact:

Provincial Chairperson | Helen Nkuna | helen.nkuna@tac.org.za | 071 836 1671

Provincial Manager | Moses Makhomisani | moses.makhomisani@tac.org.za | 073 187 0813

Campaign Manager | Lotti Rutter | lotti.rutter@tac.org.za | 072 225 9675

 

The report can be downloaded here: https://tac.org.za/files/Limpopo-report-and-full-memorandum-2-November-2017-FINAL.pdf

The summary of demands can be downloaded here: https://tac.org.za/files/Summary-of-demands-Limpopo-FINAL.pdf

The memorandum can be downloaded here: https://tac.org.za/files/Limpopo-memo-for-readout-2-November-2017-FINAL.pdf

The results of the facility monitoring in October can be downloaded here: https://tac.org.za/files/LIMPOPO-OCTOBER-SURVEY-RESULTS-FINAL.pdf