Adam Nhlongo couldn’t believe the state of his local clinic. It was a hot day in Giyani in South Africa’s Limpopo province and he needed to collect his chronic medication. There were no shady or seated spots for waiting patients, so he joined the long queue in the hot unforgiving sun; no nurses were available, he was told, because they were all eating lunch.

He was later ordered to return the next day and left, empty-handed. When he did finally see a nurse the following day, he received no consideration or courtesy, let alone medical advice. 

Photo: Ritshidze Project.

Limpopo is one of South Africa’s poorest provinces; data from Statistics South Africa found that it had the highest headcount of adult poverty (67.5%). It is also home to a public health system routinely described in headlines with words like “fiasco”, “disaster” and “shame”. Many in Nhlongo’s situation would likely grit their teeth and just try to get through each required visit. Instead, he joined Ritshidze.

“I got involved because I have seen how people are treated at hospitals and clinics, and I have experienced it first-hand because I usually go there to collect my medications. I have first-hand experience, so I needed to go there and make a change,” he says.

Ritshidze is a tshiVenda word that means “Saving Our Lives”. The health advocacy initiative was started in 2019 by HIV activists who realised that community-led monitoring offered a valuable way to monitor public healthcare services, hold the government accountable – and use data to agitate for evidence-driven change.

Photo: Ritshidze Project.

It’s not the first model of its kind. South Africa has high rates of HIV/Aids and tuberculosis (TB) cases; researchers have frequently documented the sort of targeted, tailored support these individuals require.

One study conducted in the Free State province shows how community-led actions can offer support and help increase the uptake of medications to both prevent and treat TB and HIV/Aids through a method called directly observed treatment (DOT). The study’s authors found that DOT can be effective in increasing the uptake of medication by TB and HIV/Aids-infected individuals. In short, community matters.  

Data is key

That’s why ordinary people are the foot soldiers in Ritshidze’s battle for dignified, effective and efficient healthcare. Its weapon? Data. “Solutions and demands come from data,” explains Project Manager Ndivhuwo Rambau. “Data helps reveal and prove that there is a problem; so, we can say, ‘Look, we’ve got the evidence … we should do something about it.”

There are six steps in Ritshidze’s process. First, community monitors in eight of South Africa’s nine provinces (Ritshidze does not operate in the Northern Cape) conduct quarterly visits to around 400 sites across the country. There they chat with residents, going door-to-door and conducting surveys to understand what’s working – and what isn’t – at local clinics and hospitals.

The frequency of their visits means they can track ongoing problems, improvements and new issues. They also canvass people for potential solutions, as well as offering some of their own based on their institutional knowledge and experiences from elsewhere in the organisation’s network.

Then, the data is uploaded to an open-source data collection platform called CommCare, which is used across the world to track services primarily in the public health sector. Data from surveys or other collection drives are uploaded to the platform. Data is sorted and subsequently analysed by Ritshidze members.

At this stage, they engage the Department of Health on the main challenges and propose possible solutions. Officials capture what duty-bearers commit to fix and monitor the progress. If they fail to do so at a local level, the issue is escalated to a provincial and national level. Members work to hold duty-bearers accountable to ensure they fulfill the responsibilities to the people. 

Photo: Ritshidze Project.

Incremental changes

Steps five and six are monitoring implementation and advocating for change Ritshidze’s team is pragmatic: when you’re working with a system that’s on its knees, dramatic transformations are the stuff of fairy tales. There are around 4,000 clinics across South Africa, according to FIND, a global diagnostics alliance with a regional hub in the country. Though Ritshidze has a growth plan, it is only navigating the tip of the iceberg. Its successes – and failures – are also inextricably linked to factors beyond its control, like departmental officials and employees, as well as broader infrastructural shortcomings.

So, even the smallest victories are worth celebrating, as illustrated by a June 2022 report. Facilities in Mpumalanga were the most improved across the eight provinces that Ritshidze monitors. Patient waiting times dropped from more than four and a half hours over the last year to just more than four. Staffing levels were up; 41% of facility managers reported that they had enough staff to ensure patients received sufficient care. 

It’s clear from these infinitesimal shifts – four hours remains an unreasonably long waiting time – that Ritshidze is running a marathon, not a sprint. Simphiwe Xaba, who manages Ritshidze projects in Kwa-Zulu Natal and Mpumalanga, points out that solutions need to be implemented in the short-, medium- and long-term to really improve patients’ experiences. 

Room to grow

The organisation has big plans – both at home and elsewhere. It hopes to add an additional 200 monitoring sites by the end of this year and to do a data collection drive that targets key populations such as transgender people, drug users and men who have sex with men.

And, though it was developed for the South African context, Ritshidze’s work has drawn attention from elsewhere. Project Officer Ndivhuwo Rambau said that like-minded civil society groups (“comrades”) from Zimbabwe, Mozambique and as far afield as Haiti have sought guidance on how to adapt and apply the model in their own countries. Perhaps, soon, residents in Port-au-Prince, Harare and Maputo will also discover the power that data has to slowly, steadily, shift systems.

This article was written as part of explain.co.za’s Lede Fellowship with the Solutions Journalism Network.