Little information is currently available about how COVID-19 has affected long-term care facilities (LTCFs) in countries like South Africa. Based on the experiences of LTCFs in high-income countries, we were deeply concerned about the situation in these countries and were able to obtain funding for a study in South Africa, Brazil and Mexico.[1] Research is ongoing, but we have been stunned by the initial data we have been able to collect.

In the spirit of immediate knowledge-sharing, this blog shares some of this information with reference to two different LTCFs in the Western Cape of South Africa. There are 418 registered residential frail care facilities across the nine provinces of South Africa, almost a third of which (120) are in the Western Cape Province[2]. There is significant variation in the resources available to these facilities, driving economic inequalities in the care of older people and, presumably, the capacity of facilities to respond to the COVID-19 pandemic.

This blog draws on information provided by managers of two residential frail care facilities (or LTCFs) that cater to relatively wealthy and relatively poor older South Africans and reflects on differences in how management, staff and residents of these facilities experienced the COVID-19 pandemic.[3] This is not a carefully worked academic paper and we make no claims about the extent to which these experiences are more widely representative. Nevertheless, they demonstrate the need for a more systematic set of public policy responses to these different forms of vulnerability, along the lines of this framework (https://corona-older.com/2021/07/20/an-emergency-strategy-for-managing-covid-19-in-long-term-care-facilities-in-low-and-middle-income-countries-the-ciat-framework-version-3/.)

 

GENERAL FEATURES OF EACH FACILITY

Facility One

This LTCF, located in a low-income neighbourhood, was built over 50 years ago and was described as resembling a boarding school. There are no private rooms and many of its 136 residents live in single-sex dormitories, each containing up to 20 people. Toilets and bathrooms are located outside the dormitories. The manager commented: “It’s a challenge to keep them all together in peace.”

The facility falls under an umbrella non-profit organisation that runs other frail care centres and retirement villages in the region and is registered with and funded by the DSD, indicating that it should meet most required norms and standards. However, like many facilities providing services to low-income residents, the facility was in a precarious financial position prior to COVID-19. Financial operations are almost entirely funded from two sources: grants from the Department of Social Development (DSD) and residents’ personal old age grants (non-contributory means-tested government pensions), which they are required to hand over to the NGO which runs the facility. Together, these two sources amount to about US$420 a month per resident, which only permits very basic levels of care and the ratio of employees to residents is one to ten. According to government regulations, the ratio of caregivers to frail older persons should be 1:5, but this is challenging in most state funded facilities given the low subsidies provided by the DSD relative to the cost of care and the facility often relies on local donations of food and other essential products. Many residents complain about losing their pensions, which is typically their only source of income. According to the manager:

They don’t understand there is no money. They say, “Give me my old age grant, then I’ll live on the street. They don’t even have money for cigarettes. They sell our chairs over the fence to the school for cigarettes!

The manager claimed that her budget was not sufficient to provide adequate care before the pandemic and that meeting residents’ daily food needs was a continual challenge. Occasionally, they receive small food donations from local businesses.

Facility Two

This LTCF is part of a larger ‘retirement village’ and located in an affluent leafy, suburb. As well as the LTCF, this includes 680 privately-owned individual properties, with limited provision of assisted living services. The LTCF provides a combination of levels of support, including assisted living, frail care and specialist dementia care. At the time of interview there were 121 residents, with around 104 staff. Some residents have private rooms, others share, up to a maximum of four per dormitory. All rooms and dorms have en suite bathrooms. The facility caters almost exclusively for affluent older people and does not receive funding or admissions from the DSD.

 

COVID CASES AND DEATHS

By 12 October 2021, Facility 1 reported 78 cases among residents (around half of their total), not including cases that went undetected. Of those, eight had died from COVID-19, along with 12 residents who died of other causes during the pandemic. Data on staff cases were not available, although the manager commented: “I’m one of the few lucky ones who hasn’t had covid”. Impressively, the manager claimed that there had been no cases of COVID-19 among residents in 2021.

Facility 2 had a COVID-19 outbreak in August 2020, with 10 registered cases among residents and 18 among the 104 staff. During this outbreak, two residents’ deaths were attributed to COVID-19, with a further resident dying because they were unable to access essential hospital treatment for a different health condition. There have been no further reported cases or COVID-19 deaths since the August outbreak.

SUPPORT FROM GOVERNMENT AGENCIES

The LTC sector in the province is primarily overseen and supported by the Department of Social Development and Department of Health. DSD has the mandate for monitoring norms and standards and supporting long-term facilities in South Africa, while the Department of Health plays a more limited role, providing medication and incontinence products and registering and monitoring dementia care facilities. This dual responsibility can cause conflicts and confusion, including during the pandemic, and there were significant disagreements over which department was mandated to provide PPE. This resulted in significant delays in providing PPE and limited provision of PPE/PPE funding thereafter, which had disproportionate impact on low-resourced facilities such as Facility 1.

Facility 1

Even before the pandemic, Facility 1 struggled to obtain basic materials from the Department of Health (DOH). The manager observed:

Three quarters of the time they don’t have stock. Nappies have been out of stock for 3 years. We must fight for gauze to treat pressure sores.

In the early months of the pandemic, Facility 1 received no PPE from governments agencies, and supplies continue to be limited. The manager resorted to making appeals for donations or purchasing equipment from the NGO’s limited funds. While they did receive ongoing telephonic support from DSD, no meaningful support was provided to the facility by the Department of Health.

Facility manager expressed frustration on numerous occasions that there was a large disconnect between the norms and standards that government agencies required them to meet and the provision if funding and support to make this feasible, especially during the COVID-19 pandemic. She noted:

They send the guidelines via email for you to implement according to the norms and standards, but not the resources…. If they come to do inspections, they want to know why there isn’t a basin in this room, why are there no hand towels? If I put them out now, the residents will take them within 10 minutes and blow their noses on them, throw them in the bin, flush them down the toilet – then the drains are blocked… I can’t change the structure of this place to comply with the norms and standards. They say there has to be a basin in all the rooms – now they mark me down… We have to replace vinyl concertina doors –they’ve been here for 55 yrs. Because they are bigger than a normal door for wheelchairs it will cost R12,700 per door and I need to replace 40… It feels like we are being set up to fail.

During the pandemic, Facility 1 was reluctant to send residents to state hospital, the manager claiming that:

They can sit for two days in a wheelchair. They don’t sleep. I don’t even know if they give them food.

Facility 2

Facility 2 was much more positive about their relationship with government agencies and the support they were provided:

The DoH was very helpful during covid with regulations, protocols, training… They gave us just the same as the state entities. Very effective and helpful. DSD also helped a lot if we were worried or struggling… They will give you numbers and help you with everything. Don’t wait for them to contact you. You’ll wait forever. Contact them and they respond.

The only criticism was:

They trained a bit late, but I won’t fault them on that because none of us knew anything. They had to get their ducks in a row first. It took them a while to do the Zoom training.

It was also noted that all annual inspections had been suspended since the pandemic started.

INFECTION CONTROL AND LOCKDOWN

Given concerns about the rapid spread of COVID-19 and lack of health system preparedness, South Africa instituted a stringent lockdown on 26 March 2016, well ahead of community transmission of the virus. Concerns about spread through LTCFs resulted in the lock-down of these facilities in early March and lockdown regulations allowed no visitors or volunteers and only very strict exits and entries from facilities for most of 2020, with lockdowns being put back in place in the context of the second and third waves in December 2020 and May 2021.

Facility 1

As was the case with most facilities, Facility 1 put in place strict lockdown protocols well before significant numbers of COVID-19 cases were reported in the province. Many residents are immune compromised due to HIV or other conditions, so the management tried to implement a strict lockdown protocol. Family visits were completely suspended for much of 2020. During 2021 measures were relaxed to some extent, although children are still banned from visiting. Residents are now permitted to go outside the facility in some circumstances, the manager noting:

When they go on family visits, they must go out for seven days and come back with a negative test. If they go out for two to three days, or if they go to a wedding or funeral, I isolate them.

During the period of full lockdown many of the residents struggled to adjust to the new protocols. Few had cell-phones and the NGO lacked the resources to facilitate virtual meetings with relatives. The manager observed:

Some of them thought I tried to keep them in jail… They got cabin fever… They kicked out the windows, hit each other. Their backgrounds are that they fight for everything. To get that out of them is a challenge… They have no respect because nobody respected them.

More generally, it was difficult for Facility 1 to impose infection control protocols by either staff or residents, due to a lack of protective equipment and other materials, as well as a reluctance to comply among some residents. The Facility’s small pre-pandemic budget was further stretched, due to the need to purchase PPE and additional cleaning materials.

Facility 2

From the start of the lockdown strict infection control measures were enacted. According to the manager:

We washed uniforms onsite overnight. We organised and paid for our own staff transport for a long time. We did training all the time…. We had to remind and re-train: washing hands, sanitising, masks. Everyone had their own sanitiser and masks. We were very extreme. We had a machine that ‘oxinates’ everything that came in.. We F10’d the wards every 48 hrs (sanitising agent, backpack sprayers). We cleaned like crazy. We sprayed feet and went crazy. We’ve relaxed a bit – we still do it now and again.

She added:

In the beginning you couldn’t find PPE. We had masks made which was expensive – gloves were expensive. The company had a lot of money invested in PPE – it was unbudgeted.

A further challenge was that:

Dementia patients can’t understand, and they wander around.

Despite having more resources available to facilitate virtual communication, the manager indicated that residents and families struggled tremendously with the ban on family visits:

The families were difficult because they couldn’t see the residents. We could blame the DSD.

We saw what the lockdown did to residents. We saw it every day … mentally. We tried our best to be the family – we video called, Skyped and bought an i-pad so they could see. We tried to do activities with the residents. We took them outside. The company invested money in visiting rooms with screens and pipes so they can hear. We tried everything to get the people to see their families… Someone was appointed in frail care to entertain residents because they were not allowed out. They were entertained in the dining areas with sand art, music days, table tennis.

The manager added that the lockdown led to a high degree of depression in the wider retirement village complex, including “two attempted suicides, which you don’t see a lot in a retirement estate.”

During 2021, these restrictions were considerably relaxed and the manager was able to make some more positive observations:

It’s better now – the morale is better now… The pandemic: Brought us closer to the residents because we were their families.

STAFFING ISSUES

Facility 1

Although Facility 1 was unable to provide data on cases of COVID-19 among staff, it was evident that infection had been widespread, especially in the early months of the pandemic. This led to a very high level of absenteeism:

Having 20 staff off all at once with a staff of about 46 – half ended up with covid having to isolate.

The manager suggested that high rates of infection among staff were in part due to their own difficult living conditions in low-income communities where capacity to practice physical distancing and apply appropriate hygiene protocols is unrealistic.

You can understand it because living in an RDP house[4] with 6-8 in a house with two rooms.

In the beginning about 20 staff were infected. In 2020 the biggest challenge was having staff available. Absenteeism greatly increased workloads for remaining staff, which in turn was a cause of additional absenteeism:

They’re working hard, going through burnout, experiencing emotional and physical changes due to covid. We gave them a very small raise (about 1-1.5%) but we haven’t received an increase from the DSD.

Facility 2

Many of the impacts of the pandemic on staff were similar to those reported for Facility 1. For example:

During COVID it was a challenge as if one staff member tested positive, the whole shift was sent home. We were just learning about Covid. We used a home-based care nursing agency temporarily – but it was better to use own staff on extra shifts because they know the patients. Also, it was more expensive to use an agency.

The staff got depressed and overworked because they were the families to the residents for this time. All the new things happening. Everyone outside felt depressed – keeping the morale up was difficult – to keep residents and staff feeling positive. It was difficult because you were not allowed to do team buildings. I tried meeting one shift at a time at 6 am and speak about everything.

On a more personal note, the manager added:

I had PTSD – I was in a state because you feel so responsible and there’s nothing you can do to change it… And what it did to us as staff – it took away a lot of our family life – we were so tired. They were all at home and didn’t experience the same anxiety we did battling the ‘thing’ that we didn’t understand.

VACCINATION

Facility 1

By October 2021 most residents of Facility 1 had received at least one dose of COVID-19 vaccine. However, the process of administering the vaccinations had been far from perfect. According to the manager:

At first, I had to beg them to come out to our facility – they wanted us to take the residents there… When they came, our manager was still preparing a list of employees and residents who wanted the jab. I had to hand it over to them. If they had sent an email beforehand explaining what was necessary, we would have had it all ready. We started running around, so we looked disorganised. The residents don’t have cell-phones, so I had to use my phone to register them / apply for the vax passport….  It was difficult to get hold of family members who needed to give consent because some elders are unable to decide for themselves. In some cases, their number no longer existed, or the phone had been passed on to someone else, or they couldn’t afford to phone back….

What was problematic was that they brought members of the public into our facility where we have restricted visitors. They told the public that there was a clinic at our facility. But we are not a covid clinic. The vaccine team were to come out especially for our residents the elders, not for the wider community…

Twenty of our 136 residents did not want the vax initially. It was their choice. Now they want it, but the vaccine people won’t come out again. And some of these people are bedridden, so I can’t take them to the clinic. Now they are saying they don’t have jabs available. I’ve been asking for weeks to vax 20 people – they don’t even answer me.

By the time of interview only around half of staff had received one or more doses of vaccine. The manager said that this reflected the personal choices of staff members. Many were not vaccinated when the team visited the facility. For some of these, remaining unvaccinated was a personal choice. For many, however, it was because obtaining a vaccine outside the facility was often difficult, especially in the first part of 2021 when only the Johnson and Johnson vaccine was available via clinicals trial to health and care workers at select sites and public vaccination sites were not widely available. Speaking of her own experience, the manager noted:

I went to Hospital X and waited from 8 to 4 pm without being attended to. That’s why people don’t go.

Facility 2

This facility’s experience of vaccination was considerably more positive. Staff included a number of registered nurses, two of whom were trained and given temporary licences to administer the vaccine. A nearby government hospital sent a vaccination team and 400 residents of the LTCF and wider retirement village were vaccinated in a single day. A further 200 were required to travel to the hospital to be vaccinated. According to the manager:

They are super-effective – I recommended the residents in the houses to go there. They set up a vax clinic – a beautiful place – so well organised. The staff are super. You never waited.

By the time of interview, only three residents had not been vaccinated. Six staff had not been vaccinated, out of choice and they were not permitted to work in the frail care section of the facility. According to the manager: “We are not pushing them to have it. Still a choice”.

 

FINAL COMMENTS.

Despite the large differences between these two LTCFs, they have faced similar sets of challenges during the pandemic. Both have been affected by COVID-19 mortality and infection, as well as by staffing issues and the challenges of infection control. Both have struggled to meet these challenges, notwithstanding the heroic efforts of some staff. At the same time, it is evident that Facility 1 has been especially exposed to the effects of the pandemic and has had fewer resources with which to face it. This facility manager’s accounts demonstrate the impossibility of providing adequate care to residents with the limited available resources and a lack of external support.

This is not an academic paper. We have not conducted systematic analysis across these two facilities and the other ones included in our study. We plan to complete our analysis and submit papers for peer-reviewed publication in the next few months. But for now, we simply want to share some of the accounts we have heard.

REFERENCES

[1] UKRI GCRF/Newton Fund Agile Response Fund, EP/V043110/1.

[2] Currently only facilities offering “residential frail care services” need to be registered with the Department of Social Development (DSD) and are included in these statistics. According to the Older Persons Act of 2006 a frail older person is an older person in need of 24-hour care due to a physical or mental condition which renders him or her incapable of caring for himself or herself. All frail care centres must be registered with the DSD regardless of whether they receive DSD funding or not. Approximately 117 facilities are funded (around 9000 residents) and there are also around 183 private facilities in the province, many of which are retirement villages or assisted living centres and are therefore not registered (although most have been reporting COVID-19 data to the government).

[3] For some wider context about the country’s long-term care system, see https://www.cambridge.org/core/journals/journal-of-social-policy/article/longterm-care-for-older-people-in-south-africa-the-enduring-legacies-of-apartheid-and-hivaids/8DFDAA029A7B1EA3AAE708E31B6CC0F7

[4] Government Housing Subsidy (RDP) houses are allocated to qualifying low-income families.