Ritshidze monitoring unmasks severe service slide in Gauteng, KZN, and Eastern Cape post-Pepfar cuts

In the wake of the US President’s Emergency Plan for Aids Relief (Pepfar) funding cuts that took place earlier this year, the community-led monitoring group Ritshidze has continued to track service delivery at state healthcare facilities in Gauteng, KwaZulu-Natal and the Eastern Cape. 

Ritshidze’s efforts have revealed challenges such as staff shortages, increased waiting times and deteriorating filing systems across the provinces, with the group calling for urgent interventions by duty bearers in the health sector, namely the national and provincial health departments.

In some regions, more than 90% of facilities reported staff shortages.

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 took place.

“We hope all this effort to understand the impact at facility level will be taken seriously by district, provincial and national health departments — and that concrete action will follow. As the TAC and Ritshidze, we have had to sacrifice a great deal to prioritise getting this data collection done,” TAC General Secretary Anele Yawa told Daily Maverick.

Facility data was collected from 326 public health facilities in 16 districts across six provinces.

Read more: Ritshidze report spotlights ‘system-wide slide’ in basics for health facility standards after Pepfar cuts

Gauteng State of Health

In Gauteng, 84% of health facilities surveyed said there were too few staff, with 38% of these facilities blaming the shortages on Pepfar-implementing partner staff no longer working, or working at a reduced capacity at clinics.

Ritshidze reported: “Other facilities blamed staffing shortages on unfilled vacancies and there not being enough open positions on the organogram in the first place. Gauteng reported the most vacancies out of all provinces monitored by Ritshidze.”

The community-led monitoring group collected facility-level data in four of the province’s districts, including the City of Tshwane (20 sites), Ekurhuleni (20 sites), Johannesburg (28 sites) and Sedibeng (11 sites).

Gauteng had the third-longest waiting times out of the six provinces monitored by Ritshidze, with the majority of healthcare users surveyed blaming the delays on staff shortages.

The concern with long waiting times was that people were more likely to interrupt or disengage with treatment, according to Yawa. He noted that many individuals were unable to spend hours at clinics due to pressures such as work, caring for children and running households.

More than 50% of health facilities monitored by Ritshidze indicated that their filing systems were in “bad condition”, with a worsening of systems across all districts since January.

“In Johannesburg, filing systems were in a terrible state with 67% observed to be in a bad condition — 28% more than in January 2025. Similarly, 65% of the City of Tshwane’s filing systems were observed to be in a bad condition,” said Ritshidze.

“Given that Pepfar partners have often supported the maintenance of clinic filing systems, it is sensible to think that the increase in filing systems in a bad condition in Johannesburg and Sedibeng is correlated with the Pepfar implementing partner no longer working, or working at a reduced capacity.”

Before the Pepfar cuts, Gauteng was among the better performing provinces when it came to providing people living with HIV with a three-month supply of antiretrovirals (ARVs). However, Ritshidze’s report showed that only 75% of people were getting a three-month supply or longer during the most recent data-collection period, down from 81% in January 2025.

“Sedibeng is among the four worst performing districts out of all those monitored by Ritshidze. Extra trips to clinics with too few staff, bad filing systems and very long waiting times need to be urgently fixed,” said the community-led monitoring group.

The report also showed that 24% of sites reported fewer or no staff to conduct HIV viral load tests post-Pepfar disruptions.

Daily Maverick reached out to the Gauteng Department of Health about the outcomes of the Ritshidze report, but had not received a response by the time of publication.

Eastern Cape State of Health

According to Ritshidze, since 2018 the Eastern Cape has consistently been the province where facilities reported the worst staff shortages. The most recent data collection period showed that 93% of facilities said there were too few staff. In the Buffalo City district, staff shortages were reported at 100% of the sites surveyed.

Facility-level data was collected at 40 public health facilities in two of the province’s districts: Buffalo City (20 sites) and OR Tambo (20 sites).

“Most [facilities] blamed unfilled vacancies, and not enough open positions on the organogram in the first place. But others blamed Pepfar-implementing partner staff working at a reduced capacity. While Pepfar implementers are still active in both Buffalo City and OR Tambo, 80% of sites monitored in Buffalo City said they were working at a reduced capacity — only adding to the pressures on already overburdened staff,” said Ritshidze.

The Eastern Cape had the second-longest waiting times out of all provinces monitored by Ritshidze, with 69% of the healthcare users who experienced delays blaming this on a shortage of staff at facilities.

Among the sites the group visited, 53% indicated their filing systems were in bad condition, up from 48% in January 2025.

“[The] condition of the filing systems has been improving in OR Tambo… In contrast, Buffalo City’s filing systems are reported to be in a disastrous state, with 80%... in a bad condition,” said Ritshidze.

Most facilities reported that viral load testing services had not been affected by the Pepfar disruptions. When it came to the supply of ARVs, 88% of healthcare users living with HIV indicated they received a three-month supply or longer.

Camagwini Mavovana, the spokesperson for the Eastern Cape Department of Health, said that long waiting times in the OR Tambo and Buffalo City districts were due to a shortage of administrative personnel and inadequate space for filing and archiving in facilities, among other challenges. 

The department was seeking to address this through “ministerial intervention” to employ doctors, nurses, Health Systems Trust data capturers and Emergency Medical Services personnel.

“This will have a positive impact on waiting times,” said Mavovana.

She added that emergency funding, authorised through section 16 of the Public Finance Management Act, was being used to “bridge the gap” left by the Pepfar cuts.

“There is a need to market the appointment system strategy [to healthcare users and] procure filing cabinets,” said Mavovana.

The department aimed to improve filing systems by using an external space for the archiving of records, with the support of the Records Management Unit, she said. In the interim, it was assessing individual facilities to establish plans for archiving inactive files.

KZN State of Health

In KwaZulu-Natal, there were increasing concerns from both public healthcare users and facility staff that there were too few staff to provide for

the needs of people using state health facilities, according to Ritshidze. 

Facility-level data was collected at 60 public health facilities in three districts: eThekwini (20 sites), King Cetshwayo (20 sites) and uMgungundlovu (20 sites).

Among the facilities surveyed, 90% reported that there were too few staff, with most blaming these shortages on unfilled vacancies or the limited posts at clinics.

“Others blamed Pepfar-implementing partner staff not working or working

at a reduced capacity. Following the Pepfar disruptions, 27% of [healthcare users] in King Cetshwayo said staff shortages were worse,” said Ritshidze.

Despite this, KZN continued to have the shortest waiting times among the provinces monitored by Ritshidze, with little change from January 2025.

“The condition of filing systems has worsened in KwaZulu-Natal following the Pepfar disruptions, mostly in King Cetshwayo… where filing systems are reported to be in a disastrous state, with 89%... in a bad condition,” said Ritshidze, noting that King Cetshwayo district had the most filing systems in bad condition out of all districts it monitored.

The group noted a significant drop in the number of people living with HIV who received a three-month supply or longer of ARVs at health facilities, going from 84% in January 2025 to 53% during the data-collection period.

Only 13% of facilities reported that HIV viral load testing services had been affected by the Pepfar withdrawal.

Daily Maverick reached out to the KZN Department of Health about the outcomes of the Ritshidze report, but had not received a response by the time of publication. 

Recommendations

Despite a circular from the Director-General of the National Department of Health, Dr Sandile Buthelezi, greenlighting the six-month dispensation of ARVs for eligible patients in February 2025, Ritshidze noted that there had been a very limited implementation of this policy across the provinces.

“We support 12-month prescriptions and scaled implementation of six-month supply to decongest clinics, reduce waiting times and make care more convenient,” said Yawa.

He urged national and provincial departments of health to fund and fill vacant clinic positions, while ensuring there were posts for sufficient counsellors and data clerks to relieve overburdened clinical staff.

Ritshidze has advocated for a greater number of external pick-up points for ARVs to reduce congestion at clinics. It noted that many community-based organisations were ready to run pick-up points in their communities, but were held back by limited funding opportunities. DM