Understanding gaps in implementation of national HIV policies in South African public health facilities using Ritshidze community-led monitoring data

BACKGROUND: South African HIV policies and guidelines incorporate human-rights and people-centered approaches to healthcare, a critical strategy for closing retention and viral suppression gaps. These standards include guidelines for friendly, efficient, and private/non-coercive healthcare services that are not often captured by traditional service delivery monitoring. Using data from the Ritshidze Community-Led Monitoring (CLM) Programme in South Africa, we describe the extent to which quality of care aspects of policies are being implemented with fidelity.
METHODS: Ritshidze community monitors conducted electronic surveys at 402 PEPFAR-funded facilities in South Africa, surveying 7,654 public healthcare users from April 1 to June 30, 2021. CLM data from indicators on friendliness of staff (n=2), efficiency (n=1) and privacy/non-coercion (n=2) were compared to HIV-related National Department of Health (NDOH) standards, charters, and guidelines to measure the extent to which public healthcare users reported adherence to national policies.
RESULTS: CLM indicator alignment with NDOH guidelines on friendliness was low, with 16% of PLHIV reporting staff are welcoming when they return to the facility after missing a visit and 62% of respondents reporting that staff are always friendly and professional (Table 1). Alignment with guidelines related to privacy/non-coercion was higher, with 90% of PLHIV reporting the facility keeps people's HIV status confidential, and 79% of respondents report being told they could refuse to give the names of their sexual partners during index testing. Clinic efficiency was rated generally low, with 31% of respondents reporting the queue at the facility is not long. Provincial variation was reported, with ranges from 14% (efficiency) to 29% (non-coercion).

Table 1. Comparison of NDOH guidelines and CLM indicators

Category	Guideline (Source)	CLM Indicator	National (Provincial Range)
Friendliness	'All staff in the facility are welcoming, acknowledge it is normal to miss appointments and/or have treatment interruptions, support and empower patients to improve retention after re-engagement.' (Standard Operating Procedures: Minimum package of interventions to support linkage to care, adherence, and retention in care, 2020)	% of PLHIV reporting staff are welcoming when they return to the facility after missing a visit	16% (4-25%)
	'A positive disposition displayed by health care providers that demonstrate courtesy, human dignity, patience, empathy and tolerance.' (The Patients Right Charter, 2019)	% of public healthcare users reporting staff are always friendly and professional	62% (51-72%)
Privacy/non-coercion	'Voluntary, freely, and no-coercive: The principles of human rights should be maintained. The index client may opt out of/withdraw from ITS at any stage without providing a reason and without punishment or denial of other services.' (Standard Operating Procedures for HIV Index Testing Services, 2020)	Among public healthcare users reporting having participated in index testing, % reporting they were told they could refuse to give names	79% (64-92%)
	'Information concerning one's health, including information concerning treatment may only be disclosed with informed consent, except when required in terms of any law or an order of the court.' (The Patients Right Charter, 2019)	% of PLHIV reporting they think the facility keeps people's HIV status confidential and private	90% (77-95%)
Efficiency	'Patients are attended to within an acceptable period of time and in accordance with their needs.' (National Core Standards, 2011)	% of public healthcare users reporting they don't consider the queue at the facility to be long	31% (22-36%)

CONCLUSIONS: In South Africa, CLM data highlights substantial gaps and provincial variation in the full implementation of policies meant to protect the rights of people in South Africa to adequate healthcare services. CLM data should be used by the NDOH to monitor and address gaps in the implementation of policies to ensure friendly, efficient and private/non-coercive service delivery.

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