Update on HIV patient transmissions
On July 9, the last influx of patients receiving antiretroviral (ARVs) and tuberculosis (TB) medication at Ndlovu Care Group came to collect their medication for the last time at the Limpopo facility. They also received referral letters to refer them from the non-profit facility to government facilities. More than 3,700 patients have gone through a similar process of patient transfers in the last three months.
The patient transfer is now complete – but important questions still remain. The South African newspaper “Daily Maverick” has now published a comprehensive and detailed report on this process. It also sheds light on the background and the role of the national Department of Health.
Please take the time to read the full report, which you will find translated below.
You can find the original article in English at:
https://www.dailymaverick.co.za/article/2018-09-05-spotlight-for-these-patients-the-future-is-not-a-game-it-is-a-matter-of-life-and-death-part-1/
For these patients, the future is not a game – it is a matter of life and death (Part 1)
A patient transfer process in Limpopo that has been marred by controversy and legal battles has jeopardized the welfare of 3,774 patients and raised questions about the provincial Department of Health’s commitment to patients.
On July 9, the very last patients receiving ARV and TB drugs at Ndlovu Care Group (NCG) came to collect their drugs from the facility for the last time. They were handed referral letters to transfer them from the non-profit facility in Elandsdoorn Municipality, in Moutse, to government facilities. More than 3,700 patients have gone through a similar process in the last three months.
Patients urge court decision
On paper, it should have been a straightforward transfer as a result of a three-year contract between the Limpopo Department of Health (DoH) and NCG, a registered non-profit NPO. As the Department of Health and NCG could not agree on an extension of the contract, the patients tried to enforce this by court order.
The first appeal by a group of patients ended without a hearing. The parties have agreed on a resolution according to which Limpopo DoH and NCG must agree to a three-month contract extension and a joint implementation plan for the transfer of patients from the NCG (the extension had already been discussed by DoH and NCG prior to the legal dispute).
Ministry of Health refuses to cooperate
The plan called for the Limpopo DoH to enlist the assistance of the Office of Health Standards and Compliance (OHSC) to assist in the evaluation of facilities to which patients would be transferred and required that reports on the implementation of the patient transfer plan be provided to applicants by July 2, 2018.
The Limpopo DoH and the NCG signed the agreement for three more months, during which the patients were transferred to public facilities. The NCG wrote a report from its perspective, which it provided to the claimants by July 2, 2018. Although the DoH was asked to contribute to this report, this was never done.
Patient transfers accompanied by angry protests
The transfer was marked by angry protests from the community and sparked accusations of racism, intimidation, arrogance and a lack of transparency and communication.
The South African Human Rights Commission (SARHC) has been involved in monitoring the transfer process and both SECTION27 and the Treatment Action Campaign (TAC) have also been involved. SECTION27 supported the Ndlovu Care Group as legal representative.
SECTION27’s Sasha Stevenson says Ndlovu has a good track record of providing quality care to the community. “The two parties to a contract have the right to decide whether to renew that contract when it expires,” she says. “But more importantly, it’s the right of people who use health services to continue to use them and not have the quality of those services deteriorate. And the quality of service at NCG has been high.”
The TAC has conducted its own clinic visits to ensure that no patients fall through the cracks and they will continue to monitor the clinics over the coming months. However, TAC is waiting for the Limpopo DoH to provide information on existing ART patient numbers at the facilities so that a baseline can be established for future comparisons.
South African Human Rights Commission opens investigation
The SAHRC’s province-wide investigation is the result of what is described as the “extremely concerning status of service delivery to members of the public seeking assistance from public health facilities.”
However, the SAHRC itself has become the target of angry tweets by the Limpopo DoH, which has accused the commission of “blatant lies” over the findings of a surprise SAHRC visit to Polokwane Hospital (Pietersburg) in mid-June. The SAHRC reported that expired food and medicines were being distributed to patients there.
Health Minister sees AIDS as a “black disease”
Minister of Health Dr. Phophi Ramathuba’s recent tweets and public comments, which include referring to HIV/Aids as a black disease and implying that people with HIV/Aids are to blame for being infected, have been roundly condemned. Ramathuba is at risk of being taken to the Equality Court over these comments. Her department has also been asked to apologize to the SAHRC.
SAHRC Commissioner in Limpopo Victor Mavhidula says the legal intervention has been deeply polarizing. Mavhidula says he understands how discrepancies and allegations brought to their attention may have impacted on the decision of non-renewal by the DoH. He points out that there are issues such as clarity on the exact contract value, clear separation of revenue streams for maintaining various operations at Ndlovu and reporting protocols for research findings at their on-site research facility.
SAHRC pleads for patients’ rights
However, Mavhidula says the goal now is to ensure that patients are considered and don’t end up defaulting when they seek treatment or their health is at risk.
He adds: “It doesn’t matter where you want to receive your medicine, it is your right to be treated anywhere in South Africa and the SAHRC reserves the right to monitor the transfer over the next few months.”
This comment contradicts the prevailing argument that Limpopo DoH funds should not favor clients from outside the province.
“They send me to these other clinics to die”
All the fighting and renegotiating of the Ndlovu contract is futile for Michael Mampuru and his wife Colet. Both were patients at Limpopo’s Ndlovu who received ARV treatment and care there.
“They send me to these other clinics to die,” says Michael. He is a giant of a man, 55 years old, but he also remembers a time when he was almost defeated by HIV. He attributes his recovery and good health today to the care he received at Ndlovu.
“When I came here in 2014, my wife held me up on one side and my sister on the other, I couldn’t bear it. I slept here for two weeks, they looked after me, they fed me and I got better.”
“I don’t know what we will find on this side. The government doesn’t care about us; I think we voted for them to kill us,” says Michael in Afrikaans and Sepedi.
Advanced equipment at Ndlovu
He and Colet talk about their experiences, sitting on wooden terrace benches and tables. This is the waiting area for patients. It is immaculate. It should also be functional and patient-friendly. These little things, Colet and Michael say, made all the difference in their care at Ndlovu.
“They check everything very well here, they do my pap smear every year even if I forget and they know if you’re taking your pills properly because they talk to you – and we don’t pay anything,” she says.
Ndlovu has other notable features such as a biometric patient identification system for better data capture, record keeping and queue management. The facility reports that it never runs out of drugs due to good stock management, has private consultation hours, functioning equipment and adequate staffing.
Comprehensive Ndlovu fingerprint
The entire township of Elandsdoorn has an undeniable Ndlovu fingerprint. Over the years, the NCG set up a crèche, a children’s choir, a gym, a theater and attractive accommodation to attract doctors and specialists to this remote part of the province.
However, with the non-renewal of the state contract, 28 people were removed from Ndlovu in July. It has raised and entrenched fears about the immediate viability of Ndlovu as an employer – in an area where there are already few jobs.
Personal commitment of Hugo Tempelman
The Mampurus linger briefly before leaving for good. They shake hands and hug the staff, including Dr. Hugo Tempelman, CEO of Ndlovu. Tempelman founded the clinic in 1994, coming to the country as a young doctor from the Netherlands in 1990 to improve rural healthcare in Africa. He raised funds from Europe and introduced free ARV treatment in 2003 before the government launched its ARV program a year later. From 2007 to 2014, Ndlovu ran the program with Pepfar funding from the US government and since 2014 with funds from the Limpopo DoH.
Tempelman responds to the SAHRC’s concerns, saying they have always maintained multiple bank accounts held in trust to ensure clear segregation of funding streams and allow for proper auditing. He says their contract last year was worth R10.8 million – which covered operating costs. The laboratory costs and drugs were provided by government. These were not the inflated figures he claims they might be talking about.
“I’m not going to say we were cheaper, but we offered cost-effective care that provided patients with a counselor, a nurse and a doctor. And it worked because at least 93% of our patients in first-line treatment remained without a detectable viral load,” he says.
He adds that their research on HIV prevention and comorbidity of HIV with other chronic diseases was conducted with the approval of the Limpopo Ethics Research Committee and they adhere to standard medical research protocols and reports.
“Instead of the wild accusations, lies and confusion, I invite anyone to come and do audits or see our reports – we welcome everyone,” he says.
Soon after founding the clinic in 1994, Tempelman realized that medicine alone would not be enough and started feeding stations and early childhood development programs. NCG also installed much-needed water points and solar panels throughout the township.
Ndlovu has also developed specialized medical units, including one focusing on cervical cancer screening, diagnosis and treatment, as well as a hearing loss prevention program.
Tempelman admits that the transfer process has become highly charged, unnecessarily personal and acrimonious. He also insists that it is not Ndlovu trying to cling on to the contract.
Ndlovu advocates cooperation with government
“We would be delighted if we could pass this program on to the government. We did this with our ART program in Bushbuckridge last year. As an NGO, we want to work embedded and in collaboration with the government. But here in Limpopo we know that there are problems and that patients will suffer from these problems,” he says.
Tempelman has become the target of racial hatred and demonization since the patient transfer as a white man playing savior to black patients. He says these slurs are distractions from the real problem, and he insists that Ndlovu’s activities will continue because the need still exists in the community.
Patients take legal action for further treatment
Herbert Boltini is an ARV client and employee at Ndlovu. He is also one of the three patients who filed the lawsuit against the Limpopo Department of Health and his employer (NCG was named for its involvement in the matter, but the applicants did not seek any orders against the organization).
Boltini says his fears of the government-run clinics are based on first-hand experience. He also works as a community liaison officer for Ndlovu, which means he visits the surrounding government clinics and meets regularly with the staff there.
State clinics not sufficiently equipped
“They’ll always tell you they’re understaffed and that people are waiting at 6 a.m. and will only leave late,” he says.
His own daughter, he says, was ignored for more than two hours when he recently had to take her to the emergency room after her leg was severely cut open. Members of his sister’s family complain about long lines and being denied medication for chronic illnesses. The clinics he has looked at are the Philadelphia, Kwarrielaagte and Elandsdoorn clinics – all three are referral clinics for transfer patients.
“Patients were not consulted and this decision by the Health Minister is pure jealousy of what Ndlovu has achieved. The government cannot brag about me when I am one of those who received ARVs from Ndlovu in 2003 when the government was still talking about garlic, beet and olive oil,” says Boltini.
Behavior of the Ministry of Health endangers human lives
He adds, “We are in contact with our lawyers because the DoH failed to submit their findings with the OHSC input on time. We want the Minister of Health to recognize the good work of Ndlovu. She can find ways to reduce costs without cutting the Ndlovu program and treating patients like objects that she can just carry around,” he says.
It is now a game of wait and see how legal problems and surveillance develop. But for 3,774 people, what lies ahead is not a game, but a matter of life and death.
The Limpopo DoH communications manager, Neil Shikwambana, initially agreed to a newspaper interview with Health Minister Ramathuba, but then did not respond to a subsequent communication. He also did not respond to questions sent to him by email.
Read what we have reported so far:
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COURT ORDER ON PATIENT TRANSFER
