News & Features
22nd October 2025 | Adiel Ismail
Ritshidze, South Africa’s powerhouse community-led healthcare monitor, is on the brink of shutting down. Experts warn its collapse could unravel years of progress in our clinics – just as worrying new data points to a decline in HIV services.
Tucked away in a modest office in the heart of Johannesburg’s Central Business District lies the nerve centre of the world’s largest community-led health monitoring system. It’s from here that the Ritshidze team has worked tirelessly to help people living with HIV and TB access the care they need.
But today, the once-steady hum of activity has slowed and momentum has stalled. Sweeping US aid cuts rippling across global health programmes is forcing this glowing South African initiative on its knees.
“Treatment Action Campaign (TAC) and Ritshidze are needed now more than ever,” TAC General Secretary Anele Yawa tells Spotlight.
“Following the termination of funding to South Africa, Ritshidze lost our entire funding source,” he says. “As a result, hundreds of staff members were retrenched who were doing critical work to monitor facilities and hold the health department to account.” TAC is a member organisation of Ritshidze and responsible for much of the initiative’s implementation.
Ritshidze was largely funded through US aid that was channeled through the Joint United Nations Programme on HIV and AIDS (UNAIDS) – the only dedicated UN body co-ordinating the global HIV response – which itself might be dismantled by the end of 2026.
“At the same time,” Yawa warns, “PEPFAR disruptions and the termination of funding in multiple districts will only exacerbate the existing crisis in our health system and the long-lasting impact will be of increased deaths and more HIV infections.” PEPFAR is the United States President’s Emergency Plan for AIDS Relief. As Spotlight previously reported, massive and abrupt cuts to funding from PEPFAR has hit several South African health organisations very hard.
Accountability from the ground up
Named after the Tshivenda word for “saving our lives”, Ritshidze was born out of community frustration with poor public healthcare services and a need for greater accountability in the health system. While TAC members had witnessed and helped drive the massive growth of South Africa’s HIV treatment programme, they were also constantly experiencing health system dysfunction, be it clinics running out of important medicines or unacceptably long queues.
“The more we monitored, the more we saw the near collapse of our public healthcare system – as well as a retention in care crisis as many people living with HIV were stopping their ARVs. This retention crisis can be directly linked back to the crisis in our clinics,” says Yawa.
For around five years now, Ritshidze has been collecting data on the functioning of health facilities and publishing their findings in detailed reports that have been widely covered by the media, including by Spotlight. These reports provided an independent and systematic assessment of the functionality of the health system that went beyond the types of individual stories the media might otherwise cover, or the assessments of state bodies such as the Office of Health Standards Compliance.
The organisation trained community members to collect data on nearly 500 indicators, from long queues and medicine stockouts to staff behaviour and infrastructure breakdown. Every three months, these monitors fanned out across eight provinces, visiting more than 450 clinics and community healthcare centres to capture the pulse of a strained health system.
They spoke to patients, observed clinic operations, and surveyed health facility managers. Their findings reflected the voices of more than 350 000 healthcare users, including over 200 000 people living with HIV and 45 000 key population members such as sex workers, queer and trans people, and people who use drugs, says Yawa. The project also conducted 482 in-depth interviews.
“We have clear and detailed evidence about the challenges people face that cause them to stop going to the clinic,” says Yawa.
A system buckling under pressure
What Ritshidze uncovered was often damning, and the picture was the same in many clinics across districts and provinces. Queues often snake outside long before the sun is up. Waiting rooms filled to the brim, with overworked nurses darting between patients. Hours of waiting can end up with people being turned away or leaving with only some of the treatment they need. Stockouts of medicine, especially of HIV and TB treatment, have been common. Many facilities in rural areas suffer from crumbling infrastructure. And reports of rude or hostile treatment, particularly toward queer and trans people, sex workers, and people who use drugs, remain alarmingly frequent.
“The persistence of these issues suggest significant challenges in public healthcare governance in South Africa,” says Dr Josephine Otchere-Darko, programme head of Wits RHI’s HIV/TB care and treatment programme in Ekurhuleni and Tshwane. “These problems point to systemic weaknesses including inadequate resource allocation, poor management, and insufficient accountability mechanisms,” she says.
Changing the system
The Ritshidze model doesn’t stop at data collection, they also try to help find solutions to the problems detected in their monitoring work.
“Each quarter we feedback to facilities on the evidence gathered and the recommended solutions. 4 794 feedback meetings with facilities have been held to date, with 3 509 sets of commitments being made by clinic staff,” says Yawa.
When clinics failed to respond or issues exceeded their mandate, Ritshidze escalated matters to district, provincial, and national levels.
⁉️DYK⁉️@RitshidzeSA is a Venda name meaning “Saving Lives”.
WATCH: General Secretary of Ritshidze, Anele Yawa shares stats of people living with #HIV in South Africa and the advocacy needed for an HIV-free generation. #communityledmonitoring pic.twitter.com/PBEx3BJngI
— UNAIDS South Africa (@UNAIDS_ZAF) April 23, 2024
Yawa says one key success for Ritshidze, which also proves that policy alone isn’t enough without grassroots accountability, has been in the Free State’s Thabo Mofutsanyana district. A targeted campaign, he says, dramatically increased the number of people receiving a three-month supply of ARVs, from 11% in April 2024 to 88% by the end of 2024.
This shift aligns with updated 2023 guidelines, recommending longer refills of ARVs for anyone who is stable on treatment to support better adherence.
Signs of improvement
Ritshidze’s reports often painted a troubling picture of the quality of public healthcare services in South Africa, but in recent years, at least until the end of 2024, they have also provided a record of concrete improvements at the facilities they monitor.
Average clinic waiting times dropped from nearly six hours in 2020 to just over three in 2024. It used to be that only 18% of people got a three-month supply of ARVs at a time, now it is 60%. Fewer healthcare users report having been shouted at, facilities are scoring better on hygiene, and many more people have the option of collecting their ARVs from pickup points other than the clinic.
While it is difficult to tease out why all these improvements occurred, at least some of it would have been due to the fact that Ritshidze was monitoring services and engaging with authorities when they found problems. Ritshidze makes all its data publicly available. This allows health officials, journalists, researchers, and the public to monitor trends and hold duty bearers accountable.
“While there was still more to win, what was clear is that this system of community-led monitoring and advocacy at all levels is an essential tool to fix our public health system,” says Yawa.
Some red flags
But the days of Ritshidze systematically tracking the performance of the health system may be over. Following this years funding cuts and the large number of retrenchments, a much smaller Ritshidze team conducted what may or may not turn out to be their last round of monitoring from April to June 2025.
“Following the termination of our funding, and after the retrenchment of the majority of the team, a small group of monitors was retained who carried out one round of monitoring in 320 sites across 16 districts in Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Limpopo, and Mpumalanga,” says Yawa.
In April-June 2025, through @RitshidzeSA we carried out 32,530 surveys with patients & assessed 326 facilities in 16 districts, across 6 provinces. The data reveal the impact of the PEPFAR disruptions in our clinics: https://t.co/IYOcHdPbGV
— TAC (@TAC) October 10, 2025
They surveyed 32 530 public healthcare users and what they found was concerning. When compared to their figures from January 2025: 9% fewer people are getting a three-month supply of ARVs, around 8% fewer were able to collect their ARVs from convenient external pick-up points in the community and 12% of facilities reported fewer or no staff to perform viral load tests. Only 47% of people not on treatment said they were offered an HIV test during their visit, dropping below 30% in some districts.
Yawa says six provincial reports have been drafted and they are meeting with provincial health departments to discuss their findings.
The cost of closing
Losing Ritshidze or even having a dramatically scaled-down version is a troubling prospect for a country that runs the world’s largest HIV treatment programme.
“Community-led monitoring highlights where services are working and where they’re failing – in real time. It is trusted by the system: facility, district, and national leaders now rely on Ritshidze insights to guide the HIV response,” Yawa says.
But coverage is shrinking due to the loss of funding.
“Fewer sites can be monitored. Fewer reports can be developed. Fewer feedback meetings can be held. Fewer testimonies can be collected. Our community accountability meetings have been put on pause,” Yawa says.
And while some funding was secured for the additional round of monitoring, there is still no sustained support to keep the work going. “This means future monitoring rounds are in threat, including our large-scale key population focused data collection in the community that takes place annually talking to nearly 16 000 people in 2024,” he warns.
The authors of a paper published in the South African Medical Journal argue that “Ritshidze is a unique phenomenon in South Africa. It is an excellent example of the use of data, empowering communities and social accountability in practice.”
Scaling back community-led monitoring like Ritshidze carries risks, says Otchere-Darko. “These initiatives serve as independent watchdogs, holding healthcare systems accountable and ensuring that reforms are responsive to community needs,” she says. “Without such oversights, there’s a risk of increased complacency, perpetuation of injustices, and a disconnect between healthcare providers and communities they serve.”
Professor Lillian Dudley, a public health specialist with Stellenbosch University, agrees. “We will be losing an absolutely vital source of information on the actual state of healthcare as experienced by patients and communities,” she says. “Ritshidze has improved transparency on the state of healthcare locally, and forced more accountability of healthcare providers to users and communities,” says Dudley.
Weak governance structures at clinic and hospital level have already failed to serve their purpose, and while there’s calls to improve legislation, Dudley says Ritshidze has in the meantime offered a so-called bottom-up process of strengthening transparency and accountability, which has been shown to work in practice.
“Without the bottom-up component to push for more local accountability and responsiveness to communities, I worry that policy makers will not prioritise community concerns nor recognise the urgency and importance of addressing the challenges,” she says.
Dudley adds: “We have an invaluable resource in Ritshidze that we should be integrating and ‘mainstreaming’ in the health system (without losing its independence) and should do whatever we can to ensure it is retained.”
For now, the future of Ritshidze hangs in the balance.
Disclosure: The TAC is extensively quoted in this article. Spotlight used to be published by both the TAC and SECTION27, but since late 2023 it has been published only by SECTION27. Spotlight is editorially independent – an independence the editors guard jealously. Spotlight is a member of the South African Press Council.