How rural stereotypes are being broken in Bulungula

By Ufrieda Ho

Note: This is part two of our Bulungula special feature. Click here for part 1.

A registered nurse, a social worker and one more carer – these are the people

The duo of Bongezwa Sontundu and Khunjulwa Mbi head up the Bulungula health programme

on the human resource wish list for the Bulungula Incubator health programme in the Eastern Cape.

It’s not asking for the moon, but health programme manager Bongezwa Sontundu says the added capacity would mean the four villages covered by the incubator would each have five nomakhayas dedicated to their communities. The addition of a nurse and social worker would help carers with expert input for cases that get tricky.

“We hear many problems and we see many things,” says Sontundu. Nomakhayas, like so many Community Health Workers (CHWs), often become part of the families they visit because it’s becomes a relationship of deep trust and intimate knowledge of the other.

Community health workers (CHWs) are drawn from their communities. They become the people that villagers lean on for everything from medical advice, to problems with a troubled teen, to organising an ID, sometimes helping with providing a meal or getting a sponge bath. In the villages in this remote part of the Wild Coast, it also includes helping many ill people up and down the hills of the coastal villages to get to the ferry that’s the only way to cross the Xhora River to get to the nearest clinic. In emergencies a taxi can be called but it will set a family back R800 for the trip, says Sontundu. An ambulance service exists but its reliability is always questionable and unreliable.

Nomakhayas are the consistent and reliable presence here and this adds to them being an essential element of achieving primary healthcare goals, especially in rural or remote areas.

Meaningful work

The view from the Bulungula Incubator looks out to its neighbours of other huts in the area

Rejane Woodroffe, the director and founding member of the Bulungula Incubator, says their CHW programme represents a form of meaningful work for low-skilled workers. The majority of those in the BI group don’t have high school qualifications. In turn though, their service to their communities helps many who have the least access to healthcare to stop from falling through the system’s cracks.

“A lot of what the nomakhayas do is about re-inforcing common sense and practical ways to live a healthier lifestyle,” says Woodroffe.

From the outset, the BI’s key focus has been on maternal and child health. Woodroffe says it’s a pragmatic intervention that delivers true “developmental bang for your buck”. BI has to make an annual budget from funders of R7 million really count.

She says: “If you start from day one that a woman finds out she’s pregnant and you ensure that that woman gets the right information and care for her and her baby, that kid will grow up to have the best chance of access to having a flourishing life.”

Low cost interventions

The interventions at pregnancy stage are relatively low cost, Woodroffe adds. It’s making pregnancy tests and multi-vitamins available, making sure the mothers to be have good information on nutrition and healthy living and that they attend scheduled clinic visits and antenatal classes.

It’s the nomakhayas who fulfil these roles and they continue to be instrumental when the child is born, honing in on monitoring everything to ensure that children are meeting their developmental milestones.

“It’s the normal things any mother would do, but with the nomakhayas’ assistance mothers can be encouraged to quit smoking or drinking or to eat better. The nomakhayas also monitor children’s growth, what’s going on in the home and they can alert a nurse if they suspect a medical condition,” says Woodroffe.

The nomakhayas are also at the next step of a child’s development – helping at play groups for toddlers and helping prepare them to join one of five pre-primary schools in the area that are run by BI. They even meet with parents for BI programmes like toy making from recycled objects. BI is also working to introduce appropriate technology like an app-based hearing test for children and has already launched online learning for primary school children.

The returns on investing in a child in utero are immense says Woodroffe. She knows this first hand too. The BI’s office in Nqileni, where she’s based, is a rondavel surrounded by other rondavels that are the pre-primary school for the village. All around Woodroffe, every school day, are children making puzzles in their well-resourced library, learning to write their names or reading with a teacher. It’s a no-fee paying school but parents are required to be on a roster to cook the two meals a day provided for the children. It’s a philosophy of putting value on community responsibility not on the amount of money someone has.

After their meals the children rush down the slope from their classrooms to a

Good hygiene habits instilled in the young ones is a key focus of wellbeing and health for the Bulungula Incubator’s health programme

trench where they brush their teeth after eating. There’s no running water here, but it’s no excuse for neglecting good hygiene habits. This too builds a value system that emphasises doing rather than focusing on deficiencies.

There’s laughter and giggles, learning and playing – all proof that the BI’s vision is spot on.

More proof that they’re on the right track came this autumn with the announcement that two girls who came through the BI pre-primary ranks in previous years have been shortlisted to attend the prestigious Oprah Winfrey School in Gauteng.

Hope and opportunity

The Bulungula College, another BI project, is also getting ready to open its doors for its first intake of Grade 10 – 12 school children next year. The nearest high school is about 20km away. Parents often can’t afford boarding fees or taxi fares and many children simply drop out.

“We have to give young people hope and opportunities and together with all our partners and collaborators the opening of the college is now happening and it’s a huge project for us,” Woodroffe says.

The college is a bit of a full-circle moment – closing that loop from the foetus in its mother’s womb to a fully grown high school child, ready to take on the world because many hands have helped to get her to that point.






How “Nomakhayas” beat a scabies outbreak

By Ufrieda Ho

“Nomakhayas are coming, nomakhayas are coming,” the children’s shouts

A nomakhaya tries out a new backpack made especially for the bulky scales they carry on their home visits

interrupt the quiet of a sunny autumn afternoon. The shouts are announcement, also greeting for the community health workers making their way up hills of the coastal villages along the Eastern Cape’s Wild Coast.

Of late there’s been newfound respect and appreciation for these local caregivers, the so-called nomakhayas, who are part of the healthcare arm of the Bulungula Incubator (BI), the not for profit that has started several community development projects in the region for the past almost 15 years.

Over the last few weeks this brigade of 19 women has been instrumental in eradicating a stubborn scourge of scabies that’s left few homesteads untouched, and resulted in at least one reported death of a child in the area.

The success and tenacity of this brigade of CHWs has been a powerful reminder of how effective implementation of primary healthcare comes down to strong community networks, collaboration and commitment.

Re-infection happened faster than eradication could be achieved

At the height of the scabies outbreak old and young were left were affected with the extremely itchy pimples left from the burrowing mites. In extreme cases scabies can affect the proper functioning of the kidneys (Pic: Bulungula Incubator).

Scabies is a skin condition caused by a burrowing mite (undetectable to the human eye) that lays its eggs under the skin. It leaves its human hosts with an intense itchy rash and a trail of tiny pimples. While the skin condition is easily treatable with common topical creams and preparations, the problem with the outbreak in these four villages – where there isn’t access to running water – was that re-infection happened faster than eradication could be achieved.

The local clinics and hospitals could only hand out medication, but were at a loss on how to eradicate scabies completely. When scratched sores become infected they can turn septic and pose bigger health risks.

Bongezwa Sontundu, health programme manager at the Bulungula Incubator, remembers how by the beginning of the year the scabies outbreak had taken over the four villages of Mgojweni, Nqileni, Tshezi and Folokwe that is home to about 6 500 people.

She says: “It was very bad because people would go to the clinics get the creams but it seemed like it was not working and they would just scratch and scratch.”

Photos she and health programme assistant Khunjulwa Mbi have of the worst cases they saw, reveal the extent of the outbreak. Both young and old people were affected and some people scratched till the blistered sores became raw, infected and painful.

Dr Ben Gaunt, clinical manager of the Zithulele Hospital, about 35 minutes from the Bulungula Incubator says the scabies outbreak in the region had started to rear its head in 2016. Then it just spread. For about the last nearly two years it has been endless frustration for medical staff.

“It’s a relatively simple condition to treat and it’s not life-threatening, but when it goes wrong and sores become infected it can lead to a reaction that causes problems with the kidneys.

“We saw an increased number of cases of kidney problems especially in children,” says Gaunt, confirming the death of at least one child linked to complications arising from a scabies infection.

How the programme worked

The eradication programme the BI carers undertook involved carrying out an intensive and systematic cleaning regime.

Sontundu explains that they first needed clear discussions for buy-in from the community. Then a team of five carers arrived at an earmarked homestead where the occupants would have cauldrons of boiling water on the go in time for the nomakhayas’ arrival on the appointed day. Clothes, linen, curtains and towels were boiled in the water while bedding and mats were taken out of the huts to be aired and sunned.

Items that could not be washed were placed into closed black plastic bags for three days to ensure any mites or mite eggs would be suffocated.

Two nearby households would be cleaned in the same way on the next day of

The nomakhayas’ systematic cleaning programme proved to be the most successful intervention to halt the cycle of reinfection of scabies in the villages. (Pic: Bulungula Incubator)

the programme and on the third day a fourth household would be tackled. Also on the fourth day the team would return to the first household to start the medical treatment of the occupants of the home. All the occupants had to follow the same chemical treatment regime at the same time. The treatment that’s applied topically had to be repeated after 24-hours and again on the fifth day of the eradication programme.

Sontundu says following these quite strict guidelines required the oversight and implementation of the nomakhayas. It had to be meticulous to ensure the mites, in whatever phase of their breeding cycle, could be killed at the same time.

“You can imagine if we asked people to do this all work without the help of four or five carers – they wouldn’t do it,” she says.

It was the co-ordinated and structured efforts of the nomakhayas that finally halted the cycle of reinfection of “ukhwekhwe”, the Xhosa term for scabies.

For Gaunt it’s been a relief. He says: “We have seen an across the board decline of scabies cases. The efforts by the nomakhayas show that they are one of two arms to efficient rural health care – nurses being the other.

“When CHWs are supervised and supported they have hugely positive impacts on the communities,” says Gaunt.

Some months after the intervention programme the BI carers are doing usual rounds at the home of Gogo Nophamethe Mdoseni and the six other people who live in the homestead.

Mdoseni’s usual day includes looking after her two-year old grandson Akahlulwa, grinding dried corn at the rondavel on a hill that has a view stretching beyond the crashing waves of the Indian Ocean.

Outside her rondavel her blankets, mattresses and mats are spread out on a sloping hill catching the rays of the midday sun. Other items are draped over the igoqo, the stockpile of wooden sticks that become a makeshift washing line.

“The people know now what they can do themselves to keep the scabies from coming back,” says Mbi, as Mdoseni invites the carers into her home for a mug of sweetened mageu and sweet potatoes straight from the coal fire she’s been stoking outside her hut.

“When the nomakhayas came here and said they were going to start cleaning I just let them do it, but I didn’t think it would change anything because the scabies had been a problem for many months already,” says Mdoseni in Xhosa.

“Then after a few days we all stopped itching and everyone was scratching less and I was very happy that it worked,” says Mdoseni.

She lifts up Akahlulwa’s shirt, there are still a faint line of scars from the scabies pimples that he scratched uncontrollably months before. She breaks into a big smile and so do the nomakhayas. The carers eat the sweet potatoes; they smile a little but don’t dwell on taking too much credit for just having done their jobs.

Before they leave, they bring out their scales and their exercise books, making notes about ailments and checking the general condition of the members of the household – it’s their usual routine.

Sontundu says the BI carers have since they started in 2011 served as an early warning health system in the community. They receive basic first aid training and health and hygiene training. They’re equipped to monitor health problems and being part of the community they understand the things that can affect a family here – everything from domestic violence, depression, alcohol abuse and food insecurity.

“Things are working well here now,” says Sontundu.

At a monthly meeting day at the newly built Bulungula College, the latest in a line of projects spearheaded by the incubator, the carers meet to report back to Mbi. One of the newest recruits is Boniswa Mahlaleni.

“People I haven’t met before are sometimes scared of me. They think that we nomakhaya are like a health police, nagging at them to take their medicines,” she says in Xhosa.

But over the six months she’s been with the programme Mahlaleni’s learnt that patience and persistence pays. She’ll keep donning her navy blue clothes, the signature colour of the carers, keep packing in her patient files and her scale to weigh patients and she’ll keep climbing the hills, knocking on doors or waiting for the local children to announce her arrival. It makes a difference, she knows, it can even save a life.


Fifteen years without a wheelchair – who pays?

by Elin Hem Stenersen, Volunteer Physiotherapist, Canzibe Hospital

Zukile is a 16-year-old boy with severe cerebral palsy who I met in June 2016,

Private vehicles delivering patients to Canzibe Hospital.

through the volunteer work I was doing at a rural district hospital in the Eastern Cape. He hadn`t seen a therapist since he was a year old and was found to have a developmental delay. He had since been lost to follow-up in the system, as rehabilitation services have been almost non-existent at this hospital for many years. Zukile had spent most of his days lying on a bed in his home, his body gradually growing stiff, asymmetric and skewed, with very limited options for interaction with his surroundings.

He is an intellectually present boy trapped in a body that until recently was unable to move very much; but in September 2017, for the first time, Zukile was able to sit up in a wheelchair. Of course, he is not able to sit in the ‘perfect’ way, because of the years of lying in bed, and not having the proper positioning to stop his body from moving into fixed, asymmetrical positions. His mom now puts him into the wheelchair daily. He especially enjoys sitting outside, watching his brother work in the garden. A basic need such as sitting being met can have a profound impact on the life of a child who has been confined to a bed for so many years.

Zukile’s years of suffering could have been prevented, had he been seen sooner by an occupational therapist. Also, I was told that most of the wheelchairs required for children could not be ordered in this financial year, as there was no more money. This means that several children will not receive a wheelchair this year. Will the wheelchair that has been applied for actually fit the child when it finally arrives?

I understand that wheelchairs are costly – especially the specialised ones; but I have witnessed the crucial impact an appropriate wheelchair has on a person`s function and participation in family and community life. An appropriate wheelchair allows one to be in a supported position for eating and social interaction, and to have a chance to get outside and observe one’s surroundings. It can also prevent complications, such as contractures, pressure ulcers and aspiration pneumonia – complications that would be costly for the health system and the family, and most importantly, for the person’s general health and well-being.

As the sole therapist, on a volunteer basis, for a catchment area of 143 000 people, I am aware that my efforts are a small drop in the ocean. I know my limits, and know that I cannot see and meet all the needs there are; but I can make an impact for one person. I try to see what I can do, rather than what I cannot do. I think that focusing on hope instead of despair and frustration has helped me in many difficult times; because however hard I try, I will sometimes encounter my shortcomings – professionally, administratively, and with regard to time and capacity.

That said, the appreciation and thankfulness I get from the people in the community is heart-warming. Hardly a day goes by without me feeling privileged that I get to be part of something so meaningful and rewarding.

Working in a rural hospital has taught me to value the ‘basics’ – for example, the importance and impact of basic equipment such as a wheelchair or standing frame, and what it can do in the life of a child or adult with a physical disability. My efforts have been concentrated mostly on the elementary – positioning, with a focus on elements such as pressure care, prevention of contractures, and safe feeding for those unable to feed themselves due to sickness or disability. Applying, fitting, issuing and training users and caregivers in the use of basic equipment and assistive devices such as wheelchairs, standing frames and sidelyers has also been essential. I find appropriate positioning to be critical in creating opportunities for function and participation.

I am thankful for good support from NGOs such as Timion and Malamulele Onward, who have given valuable input and equipment to support children with cerebral palsy. Surrounding hospitals such as Zithulele, Madwaleni and Isilimela have also played an important part, giving me personal and professional support.

An issue I would like to raise is my experience with the slow governmental process when it comes to assistive devices, especially wheelchairs. “The right service at the right place at the right time” is often not the practical reality. When I see a patient in need of a wheelchair, that need is now – but the process, from application until the patient receives a wheelchair, can take between one and three years. In the last quarter of 2015 and throughout 2016, I made about 60 wheelchair applications. Between January and November 2014 there had been no wheelchair applications made, as there were no employed therapists to make them. I am not sure how and when people in need of wheelchairs would receive this service, without having therapists in the area.

In September 2017 I received the first special wheelchairs for adults – two of these had been applied for in December 2015. Before then, the only available adult wheelchairs had been the basic folding-frame wheelchairs, which are highly inappropriate in an area in which the environment features gravel roads, paths and fields, with households on steep hills and in deep valleys, at times kilometres away from a basic gravel road. In Detyana community, I visited two young men with paraplegia who are unable to get out into the community without assistance. Getting to town, the hospital or the clinic is a costly affair, as the few local taxis will not pick them up; they must book special transport, at a cost of about R200 one way.

I have attended basic and intermediate wheelchair courses at the Western Cape Rehabilitation Centre, where there is talk of ‘the appropriate wheelchair’, and the human rights of people with disabilities, and that a wheelchair needs to be the right fit with the appropriate function. For me, this has created a dilemma: should I think of cost, and continue to apply for inappropriate, basic folding-frame wheelchairs for the many? Or apply for wheelchairs that have been designed for rural areas? Yes, they cost more – but they allow increased mobility for the user, and they last longer. A basic folding-frame wheelchair can last an active wheelchair-user between six months and a year. A rural, rugged-terrain wheelchair, if looked after well, can last a user between two and three years. Power wheelchairs are even less accessible, as they are quite expensive; but if this is the appropriate wheelchair for someone in a rural area, why should they not have access to it?

I was confronted with this dilemma when I forwarded my special-wheelchair applications to the regional administrator. Do you settle for the basic model, so that more people can get a wheelchair in a shorter time? Or do you apply for the appropriate choice, knowing that fewer people will receive wheelchairs?

I cannot compromise! I will apply for the most appropriate model; because the purpose of a wheelchair is to provide support, facilitate function, and give hope to people like Zukile – who is now no longer confined to a bed, but sits proudly in the sun, part of his family’s daily life.


Lifesaving programme under threat

By Ntsiki Mpulo, SECTION27

Keiskamma Trust, an Eastern Cape based  health organisation, praised around

Keiskamma Trust which survives on
donor funding is facing a crisis as money dries up for it Community Health Worker programme

the world for its incredible community work which has saved thousands of lives, is in danger after funding cuts. Ntsiki Mpulo spent time with a community worker to give us a glimpse into the important work they do in a province where the health system is unable to deliver.

“The magnitude of the HIV/Aids challenge facing the country calls for a concerted, co-ordinated and co-operative national effort in which government in each of its three spheres and the panoply of resources and skills of civil society are marshalled, inspired and led.”

This was the rallying call of the judgment in Minister of Health vs Treatment Action Campaign, in 2002. Following years of AIDS denialism, the court upheld the constitutional right of all HIV-positive pregnant women to access healthcare services to prevent mother-to-child transmission of HIV (PMTCT).

Dr Carol Hofmeyer, a medical doctor who had settled in the Eastern Cape town of Hamburg, heeded the call, and began administering lifesaving ART (anti-retroviral therapy) to the people surrounding the village. The programme started with a handful of community health workers supporting the AIDS hospice. They now have 80 community health workers who serve 47 villages and 13 clinics in the Amathole District area surrounding Hamburg, including Peddie and Nier Village.

Nontobeko Twane, a community health worker based in Mgababa village, started as a volunteer at Keiskamma Trust in 2006. She received training as a community health worker, and was then employed on a permanent basis. She hasn’t worked elsewhere, and the stipend she receives is her only source of income.

She tested positive for HIV in February 2008, and was initiated on treatment in May 2008. She has steadfastly taken treatment since that day, and continues to do so today. She understands the challenges related to taking chronic medication for the rest of her life, and is thus able to provide the support that her patients need.

She is based largely at Keiskamma Trust, which is the temporary home of Hamburg Clinic. The Trust stepped in and offered its premises as a temporary measure when the 30-year-old Hamburg Clinic building collapsed in 2012. Through this collaboration, the Keiskamma Trust community health workers have developed a close working relationship with the clinic sisters.

The services provided by the Keiskamma community health workers include home-based care visits, regular reporting to nursing staff on critical cases, and monitoring adherence to (but not limited to) ARVs and TB, hypertension and diabetes medication. Now, these services are in jeopardy, as the Keiskamma Trust faces a funding crisis.

Following the termination of a donor-funding agreement, the trust is no longer able to pay the community health workers who are part of the programme, which requires R1.2 million per annum in operational funding. The Eastern Cape Health Department has agreed to provide sufficient funding to pay 10 community health workers per annum. This falls far short of the funds required to pay stipends for the 80 community health workers in the programme.

The Keiskamma community health workers are the cornerstone of the success of the health programme in the area; without them, women such as 27-year-old Zukiswa (name changed) face certain death.

Zukiswa lives in Mgabaga Village with her husband of five years, Moses (name changed), and her two children – a three-year-old daughter and a one-year-old, son Her husband works as a mechanic, fixing cars in the yard of their small home. Zukiswa does not work, and the family’s only other source of income is the child grant received from the state. However, this is insufficient to feed the entire family; it covers formula and nappies for the youngest child, and a modest amount of food. Zukiswa’s emaciated frame is testament to this fact.

She says that she has always been slight in build; but what is clear is that Zukiswa is wasting away. She tested positive for HIV in 2015. She was initiated on treatment, but has since stopped taking her medication. Her reason for not taking her medication is that there is no food in the house.

Zukiswa cowers on the corner of the couch, the only piece of furniture in the lounge, while Nontobeko perches on a bench opposite her. Though it is not stated openly, it is clear that Zukiswa is afraid of her husband. Moses has also tested positive, but has opted not to start ARV treatment. This increases the chances that Zukiswa a will become re-infected if she does not resume her treatment.

On numerous occasions, Nontobeko has explained to Zukiswa that taking her medication means that she will increase her life expectancy, so can she raise her children. She has on occasion requested support from the Department of Social Development, to provide food parcels; however, this has only been a stopgap measure. And as Zukiswa continues not to adhere to her treatment, Nontobeko is fearful that this young mother will not survive the year.

Nontobeko, like the other 80 community health workers employed by Keiskamma Trust, provides a lifeline for the women she looks after. Without her, many would be unable to access health care at all.


Two steps forward, three steps back – a tale of the Eastern Cape clinics

By Ntsiki Mpulo, SECTION27

Hamburg Clinic

The shell of the former Hamburg Clinic stands atop a hill overlooking the

The collapsing shell of what used to be Hamburg

Keiskamma River. The 30-year-old structure fell down in 2012, as a result of strong winds. In 2017, after five long years, the Eastern Cape Health Department – in partnership with the Coega Development Corporation (CDC) – began the construction of a new clinic. According to the department’s spokesperson, the project is due to be completed in a year’s time.

On the day we visited, the site was abandoned. Our source tells us that construction – which began in July 2017 – has been slow and erratic. When it rains, workers do not come to work. This does not bode well. It is unlikely that the clinic will be completed in the timeframes promised by the department. In the meantime, Hamburg Clinic is housed in the Keiskamma Trust building.

Philani Clinic in Canzibe

The gleaming white floors and the shiny new chairs mask the reality faced by

A hopeful Philani Clinic nurse placed a sign
where the ambulance must park – if and when it ever arrives.

the healthcare users of Philani Clinic, near Ntshilini village. The clinic was overhauled and rebuilt following the publishing of the Death and Dying report in 2013, when Health Minister Aaron Motsoaledi was alerted to among others the dire circumstances under which nurses operated in the clinic.

Asbestos heaters have been removed. New sluice facilities have been built. The clinic has a pharmacy storage unit, replete with chronic medication. But all is not well.

The nurses are forced to use old equipment, which was not replaced during the refurbishment. The newly built staff quarters have no furniture. The clinic, which serves communities from Ntshilini all the way to Canzibe, is staffed by two professional nurses and a couple of community health workers, who are not employed by the department. There is no doctor rostered to visit the clinic.

In a recent case in which a two-year-old was burnt by hot water, the sister on duty did what she could to clean the wound, but had to refer the child to Canzibe Hospital, some 40 kilometres away. This is a daunting journey on any day, because the roads are so poor; and as there is no ambulance in the area, the child’s parents were forced to hire a car, at exorbitant cost.

The enterprising Sister Sylvia, who has worked at the clinic for over 11 years, has placed a sign where the ambulance ought to park – if and when it ever arrives.

Village Clinic

Two years after Eastern Cape Health Crisis Action Coalition (ECHCAC) visited

The Village Clinic, under construction since
2013 – delays have been caused by contractor issues.

the construction proposed for the Village Clinic in Lusikisiki in the Eastern Cape, the clinic is still not open.

This clinic has a long and complicated history. Since 2005, it had been housed in a building formerly occupied by AngloGold Ashanti; which was ideal, as it was located in the centre of town, and had private consultation rooms, a waiting area, bathrooms and a pharmacy.

Bizarrely, in December 2012 the Eastern Cape Health Department (ECDoH) closed the clinic down, and relocated it to a site just outside of town. From then on, two porous tents and a mobile home would serve as the clinic for the people of Lusikisiki.

The Treatment Action Campaign (TAC) and ECHCAC embarked on a series of protests, and enlisted the help of SECTION27 to begin a process of litigation. The TAC filed a lawsuit against the ECDoH on 29 May 2013, in which it named the Minister of Health as respondent. The Minister, on seeing pictures of the tents that comprised the clinic, tabled a plan to put up a temporary structure by July 2013, and to build a large, permanent clinic in the following eight to 12 months.

Since the temporary structure was erected in 2013, the people of Lusikisiki have been without a building for their clinic. They wait in the rain and the cold for their medicines, which are housed in a trailer with no refrigeration; and there are no private consultation rooms. Contractor issues have resulted in endless delays in the construction of the new clinic.

In August 2017, the contractor declared itself ready to hand the clinic over;  however, the Department of Health deemed it incomplete according to its standards. At the time of writing, it was unclear when the clinic would finally be ready to open.


Philani Clinic – A timeline of failure

by  Ntiski Mpulo

A few meters from the entrance to Philani Clinic in Queenstown, opposite the

Peeling paint welcomes patients

gate, is a black-walled tavern. On weekdays, it’s as quiet as a church; but on weekends, music bursts out of its dark interior, cars line the street and patrons dance between them, holding beer cans and bottles.

The gates of the clinic are not secured, so anyone from the tavern is free to wander in; there is but one security guard on the premises. This poses a significant risk to the patients and nursing staff of the clinic.

“When we work on weekends, the drunks come and harass us,” says Sister Annelise Koti. “I don’t feel safe at all.”

Traditionally, the clinic opened from 08:00 till 16:30 on weekdays. Since 2013, following a directive from then-MEC for Health Sicelo Gqobana, nurses at Philani Clinic were instructed by the sub-district manager, Nonceba Bhabha to begin working weekends and public holidays.

The nurses have been forced to work on weekends without compensation, and this is taking a toll. Four nurses have resigned or been fired since this unilateral decision was handed down from the district office, leaving only eight nurses rotating shifts to cover weekends. On any given day, there should be three nurses at the clinic; because of staff shortages, only two nurses work on weekends.

The nurses have questioned the decision to operate seven days a week, and have requested written confirmation from the district manager that this was indeed mandated by the department. A memorandum from the district manager to the superintendent-general confirms that the resolution to open the clinic on weekends was never signed.

“We requested the minutes of this meeting,” explains Sister Koti. “We also asked for a policy that we should work extended hours, and we asked that we would be paid for public holidays and weekends.”

empty chairs on the
weekend while nuirses are forced to be on duty without pay

The sub-district manager did not respond to their requests. Instead, according to Sister Koti, pressure was placed on the operational manager.

“She said we must comply, and complain later. She never gave us options for contesting this thing,” says Koti.

“We asked them to give us something in writing to cover us if anything happens,” she says. “For example, there could be a medico-legal claim against one of us, and we wanted to be covered. The department of health will deny you. They will say, ‘You asked to work weekends yourselves.’”

Nurses’ pleas fall on deaf ears 

Nurses at Philani Clinic report being subjected to victimisation from the district office. They have repeatedly asked their union representatives to intervene on their behalf, with little progress in resolving the issue.

“In 2015, when we spoke with the unions, suddenly the minutes emerged,” explains Koti. “But these did not specifically refer to Philani Clinic operating for seven days a week. They said in the minutes that they were preparing for opening 24 hours. But we said, ‘You can’t prepare for 24 hours with such old infrastructure. This is an old clinic.’”

The clinic is over 100 years old, and badly maintained. Paint peels off the wall where damp is creeping up from beneath the ground. The foundation is reportedly sinking. A memorandum from the clinic committee states that there is often no water available; the clinic is equipped with a rainwater tank, which runs empty and is not refilled. The memorandum also cites insufficient equipment, including a fax machine that has been without ink for nearly five years.

The clinic has been the site of contention in the last three years, with residents forcing it to be closed on several occasions. The reasons for the shutdown are numerous; clinic committee member Luyanda Nogemane places the blame squarely on the unresponsive stance taken by the MEC for Health, Phumla Dyantyi. He claims that Dyantyi has placed politically connected individuals at the district office, instead of people who care about the community.

On 30 November 2016 the committee wrote a letter to Dyantyi, accompanied by 68 signatures. However, the matter remains unresolved.

The community shut the clinic for a day in March 2017, then again in May and

a rubbish dump right outside the clinic.

June of that year, citing the non-payment of nurses as one of the key issues. “We took our grievances to Bisho, and met with Mr Myezo,” says Koti.

The HR manager called a senior manager at the district office and was told that the nurses had been paid. He advised them to set up a memorandum of understanding between the nurses and the district, but this has not been put in place. Instead, the district office issued notices stating that the nurses were off duty without authorisation, and began withdrawing money from their salaries – amounting to as much as R1 500 – if they did not report for duty on weekends. At that time, Eastern Cape Health Department spokesperson Sizwe Kupelo is reported to have said that payments to the nurses were not completed because the nurses had not submitted claim forms – but Sister Koti tells a different story.

“They targeted us,” says Koti. “In April they withdrew the money. The HR clerk would bring ‘leave without pay’ forms, which we refused to sign.”

Staff morale at the clinic is at an all-time low. Those who remain are burnt out. Between the three nurses on duty, they serve approximately 200 people per day; and on the weekends, when there are only two nurses on duty, there is no clerk to receive patients, so this task must also be performed by the nurses.

“We try not to let our issues affect the clients,” explains Koti. “Although clinic hours are 08:00 to 16:30, it is rare for us to leave at that time. We stay till after 6pm sometimes. We often don’t have time for lunch – forget about tea breaks.

“We want to be treated with dignity,” says Koti. “We have families too.”



Priority-Setting, Social Justice and Human Rights in the Eastern Cape

By Marije Versteeg-Mojanaga, Rural Health Advocacy Project

The stories of health care users experiences with the health system as published by Spotlight are devastating. Various factors play a role when patients’ rights are violated, such as poor planning, inadequate HR management, budget cuts, healthcare worker attitudes, medicine stock-outs, poor policy implementation, and well-intentioned policies that fail to address the rural context.

While there is often an interplay of factors ranging from national down to local issues, ultimately there can be no excuse when lives are lost and people experience great, avoidable suffering. In this articlepublication, I make some comments on the relation between systemic factors and deeply entrenched inequities, and on people’s struggles in realising their health rights at a local level in the Eastern Cape. I will focus on budgets and Human Resources for Health (HRH).

It is no secret that health overall, including in the Eastern Cape, has been deeply affected by the political and economic crisis that has shaken our country to its core. By Treasury’s own admission, as published in the South African Health Review (2017), health expenditure has flatlined since 2011/2012:

The picture gets worse if we take into account medical inflation, salary increases, new policy priorities and growing medico-legal claim pay-outs in the Eastern Cape – to the tune of R196 million in 2016 – which means that in actual fact, the budget for health has decreased.

In its annual report for 2016, EC Health points to the fact that under-spending in non-core health personnel posts in District Health Services to the amount of R84 255 000 (84 million rand!) has been used to fund the settlement of medico-legal claims – claims that are often caused by health-system failures. While savings on non-core posts complies with Treasury guidelines, having insufficient cleaners, kitchen personnel and procurement officers at the local level does ultimately affect the quality of healthcare services.

No matter how we look at it, in real terms the budget for health is decreasing; and this report shows not only how it affects access to health care, but also describes those most deeply affected – namely impoverished communities who often have no alternatives for care, besides digging deeply into personal pockets to book private taxis to facilities further away.

The stories of affected people covered by Spotlight originate from areas in the Eastern Cape that historically have been the most neglected. The map below indicates the persistent inequities affecting this province, with the red lines and dark blue areas representing the former Eastern Cape homelands; people living here today still experience the highest levels of deprivation, from material deprivation (e.g. lack of access to household items, such as a fridge or a phone), to living-environment deprivation (e.g. access to running water and electricity), educational deprivation and employment deprivation (Noble et al, 2014)[1]

Added to these indicators of vulnerability and inequity is the rural context, i.e. terrains difficult to navigate, long gravel roads to facilities, and dispersed populations, which further complicate access to health services for disadvantaged communities.

From a transformative and social justice perspective, government has an obligation to take this background into account when planning healthcare services and prioritising budgets and health personnel. This starts with allocating sufficient funds to health from total revenue. But while the Eastern Cape Department of Health might rightfully argue that its current health budget is insufficient to provide quality healthcare services immediately to all who need them, questions ought to be asked – whether the department, when implementing austerity measures, adequately protects and prioritises those communities most in need, most disadvantaged, and with the least access to resources to protect from further household shocks due to health-service rationing?

Family in OR Tambo District

In our publication, Cutting Human Resources for Health – Who Pays[1] (2017), the Rural Health Advocacy Project reports on its investigation into the impact of budget cuts on spending on human resources for health in OR Tambo District. According to the District Health Barometer (2017), OR Tambo District has the third-highest rate of teen pregnancy in the country, with 11.5% of deliveries in health facilities being to women under the age of eighteen (compared to the national average of 7.4%). This figure reflects poor levels of education and access to reproductive health services, and indicates risk of poor health outcomes for infants and children.

The maternal mortality rate of 198 (per 100 000 live births) is also substantially higher than the national average (133), reflecting poor access to health care during pregnancy, birth and postpartum. This is reinforced by the fact that only 40.7% of mothers delivering in facility record a postnatal healthcare visit within six days of birth.

Tuberculosis is rife in the district, with a reported incidence of 820 per 100 000 population, nearly 30% higher than the national rate of 593 per 100 000. Immunisation coverage in children is also well below government targets in this part of the country, with only 73.2% of all children in a sample of 470 children tracked over time in OR Tambo District being fully vaccinated at 24 months (Le Roux et al, 2017[2]).

We also tell the individual stories of people trying to navigate the health system to seek care for their loved ones; such as a grandmother from Nyandeni Sub-District in OR Tambo, who carries her 15-year old grandchild with cerebral palsy on her back to access the clinic. Soon she will no longer be able to carry his weight. Her grandson is malnourished, and he urgently needs to see a dentist and a dietician and have a change of medication. But the lack of such health cadres locally and the costs of travelling make it impossible for the grandmother to access these types of services. In essence, this means the household is left to fend for themselves.

Mother on her way to hospital

The hospital rendering care to the people of Nyandeni is Canzibe Hospital, serving a population of 143 000. For a long time, this hospital has not had adequate therapy services for the prevention and management of disability. Within a period of a year the hospital also lost six of its seven doctors – for various reasons, such as completion of community service, and doctors returning to their countries of origin. It took an intensive multi-stakeholder advocacy campaign of 10 months to have the doctor vacancies filled.


In the meantime a lot of harm was done, with sick patients travelling to further-away hospitals at their own cost, or deciding not to seek care at all because of the unreliability of the system and the effort and expense involved. Clinics stopped referring patients, ‘as there is no doctor available’. This in turn impacted utilisation rates, which inform budget allocations; and the unmet health need in the community increases.

Canzibe hospital today has no occupational therapists; nor does it have speech or audio-therapists, and 143 000 people rely solely on one part-time volunteer physiotherapist and one assistant. (The creation of therapy Community Service (comserve) posts for 2018 may bring some relief.) However, there is no dentist for Canzibe, and no community health workers, apart from those employed by a very well-run service delivered by an NGO – which covers only two out of 13 wards, but which demonstrate the enormous need for and impact that can made by community health workers.

The situation in Nyandeni Sub-District is just one example of many. While collaborative advocacy made a difference in this case, and helped mobilise resources for health care for this sub-district, health systems planning ought not to depend on outside advocacy. It should be based on rational, evidence-based planning tools that prioritise the most vulnerable residents in the country, first and foremost.

The release of recent organograms in the Eastern Cape makes one hold one’s breath for what more lies ahead, with smaller rural facilities facing significant downscaling; leaving a facility such as Canzibe without a CEO position, and more junior staff responsible for time-consuming and important administrative matters, such as motivating for the filling of healthcare-worker vacancies.

An analysis of rehab therapist comserve allocations further reveals very concerning inequities. In 2017, of all community service posts for therapists in the province, 30% were allocated to rural facilities, with posts for 2018 remaining disappointingly low at 31%. What is worse is that some urban facilities receive six or seven therapists, while a facility such as Isilimela Hospital – also in OR Tambo District, and serving impoverished rural communities – has no allocation at all.

To further aggravate the situation, Isilimela did have comserve therapists in 2017. Without any permanent posts and no new comserve posts, where does this leave the current patients of this catchment population? While difficult decisions need to be made when budgets shrink, we cannot take away services.

When we are faced with a financial and political crisis and a shrinking Government purse, how we set priorities matters more than ever. As a collective of citizens, communities, NGOs and other stakeholders, we can question whether health care is getting its fair share; and whether within health we are protecting the most vulnerable. We need to call for innovative solutions, such as free and reliable patient transport services; promote cost-effective measures that will improve access for the people most left out, such as investing in community healthcare workers – which, not unimportantly, also creates jobs that will lift households and communities out of systemic poverty.

But as we have seen, we must be very critical of approaches that focus primarily on utilisation rates and economies of scale, as they discriminate against historically marginalised groups. Beyond maximising health outcomes through cost-efficiencies (utilisation rates and economies of scale), the WHO urges health systems to address two other (equally important) health-system goals: 1) reducing inequities, and 2) minimising the financial burden on patients.

This means taking into account the rural location, whether or not communities can access alternative services without shifting transport costs to patients, and protecting and prioritising poor and marginalised patient groups and communities. Currently, we are performing poorly on these principles of a just health system; and the human impact is staring at us in this report.















Hospital horrors

Lotti Rutter & Leonora Mathe, Treatment Action Campaign

The hospital is full. Two young girls lie on trolleys in the main hallway. They are

An elderly patient with severe pain waits in the corridor at Kwamhlanga
hospital inMpumalanga
without being attended to. The patient’s face has been blurred
to protect their identity.

wrapped in pink blankets; drips come out of their arms and hang on the walls. One looks in severe agony. She calls out for a nurse again and again. Their mother tells us that they arrived at the hospital seven hours ago and have yet to leave the hallway. Laughter comes from the nurses’ break room. It is situated directly opposite their trolleys, but no-one ever emerges to help.

An old man with only one leg sits next to them. His drip is attached to the same set of hooks. He stands in pain. He struggles with his crutches, his drip and his file in order to slowly move down the dusty passage to the toilet. The toilet will not flush, and is dirty after people have tried. A poster haphazardly taped to the wall in the bathroom informs patients that they should “always wash their hands”. Yet the soap dispenser is empty, and there are no taps to provide water. The floor is filthy.

Overcrowding, dirty facilities, bad services and poor attitudes. This is what awaits public healthcare users at Prince Mshiyeni Hospital in Umlazi, the largest township close to Durban.

Treatment Action Campaign branches monitor the state of health care at hundreds of clinics and hospitals across the country. They are the people who need the public healthcare system to work, so they are the first to notice when it does not. Prince Mshiyeni Hospital is not alone in its dysfunction. In recent weeks, a TAC fact-finding mission has showcased the crisis in several public hospitals.

We visited hospitals in KwaZulu-Natal, Limpopo, Mpumalanga and Gauteng. And the situation in each is as dire as it is in the next.

In Limpopo, at Malamulele Hospital, people begin queuing at the old and run-down facility from 5.30am. The corridors are full. At each turn, brightly dressed women fill the hallways. Around 200 people are waiting to be attended to by only two doctors. The waiting is unbearably long. We are told that there has been no constant water supply at the hospital for three years. Patients are unable to wash themselves, and there is only a small amount of container water available for using the toilets. As we walk through the wards during visiting hours, the patients have no privacy. There are no doors or curtains. The wards smell, and the bed linen is dirty.

In Tshilidzini Hospital, more than 75 patients wait for their files. Each time a shrill voice screams out a name, the chain of people patiently moves one seat across. People have been waiting in this queue for over five hours. A few people waiting are already wearing Tshilidzini hospital gowns. One is a young man with an open wound on the back of his neck – the wound and stitches are uncovered, and he uses a wad of toilet paper to stop it seeping. And the file room is only the beginning; once they leave, patients are faced with more long queues to be attended to by a doctor.

In Elim Hospital, patients wait for files for around five hours. After collecting their files, they enter the hospital and join a long queue to be seen by a doctor. In a corridor around 100 metres long, patients on back-to-back benches fill the entire space, waiting to be seen. Those with bad coughs sit with everyone else – in a corridor with windows on just one end. As we walk around, at each turn a new queue appears. More faces are raised in hope at the sight of us. In the main hallway, a man is sitting on a trolley, under a blanket. A drip comes out of his arm. He tells us he was admitted six hours ago, but nurses have yet to find a bed for him to be moved to.

In Mpumalanga, at KwaMhlanga Hospital, the corridors are full. One old gogo

Welcome to Prince Mshiyeni Hospital. Expect long waits,
bad service and dirty facilities.

(elderly lady) lies on a trolley in the corridor, in severe pain. She struggles to move, and has not yet been attended to. People in wheelchairs are stacked together, each man’s knees squashed into the chair in front of him. Hundreds of people wait to be seen. Their eyes follow us as we pass through the corridors. One man sits in casualty with a home-made sling on his arm. After being attacked by thugs, he had attempted to access services at the hospital. An X-ray had been taken the night before – yet only a day later, his file has been lost. He is told to go and submit an affidavit at the police station, and return. He has no money, and has received no painkillers. The young man sitting next to him has been waiting for five hours. A baseball cap covers a bloody stain on the back of his head.

In the most well-resourced province, Gauteng, the recently refurbished Thelle Mogoerane Hospital still suffers the same level of neglect as before. Casualty is overcrowded, and the queues last for hours. People sleep in the corridors. Patients bleeding and in critical condition sit with everyone else. A psychiatric patient is seen wandering around the wards. We are told that for days, patients have been fed porridge for every meal. One woman shows us an X-ray of her broken jaw. She had been sent home with just a Panado for the pain. Another woman told us that post-labour, the doctors had sewn her vagina shut – when she returned to question them, they told her she must have been born that way. Another woman explained how, during labour, doctors took another woman into her space in theatre. Eventually, after waiting the whole day to be seen, she gave birth to her baby. The baby was green, and died six days later.

Poor management, budgetary constraints and a lack of care for the needs of patients plague these public facilities. And it is the people who suffer. In order to expose these crises, and hear from the people who need to use these services, TAC will be holding public hearings and showcasing people’s stories in the run-up to World AIDS Day.

As we leave Prince Mshiyeni Hospital through the abandoned trolleys, a woman sits sobbing in a wheelchair. Under a blanket her feet are badly swollen, and she struggles to breathe. We can see the fear in her eyes. She has just been discharged. A nurse leaving the hospital passes by; we try to engage with her to re-admit the woman, but she informs us as she rushes away that she will let the security guard know he must look for the woman’s friend. After TAC intervenes, she is re-admitted. Upon being examined, she is diagnosed with pneumonia and cryptococcal meningitis. She is moved to a cold and overcrowded ICU ward, beds mere centimetres apart. She has not been allowed to keep her blanket, and is visibly shaking when we visit.

When we eventually leave the facility, the young girls cocooned in pink are still where we found them in the dirty corridor, hopeless, still waiting for help.

A litany of atrocities at Prince Mshiyeni Hospital
- A wheelchair lies abandoned on the pavement, and trolleys are scattered across the casualty entrance of the hospital. Dirty rags line the floors as we enter. We are greeted by dust, dirt, and dirty chip packets.

- Family members push patients up and down the hall on trolleys. One patient looks in severe pain, lying on her side on a trolley; she rests her head on a water bottle that acts as a pillow.

- A diabetes patient waits to collect chronic medicines. Last month she waited through the day until 11pm, only to have to return the next day. Before speaking to us today, she has already waited for over eight hours.

- Paper files lie on the unattended counter for anyone to look at. One woman waited for eight hours until they located her file.

- At 4.30pm, more than 100 people still need to be seen. Every corridor of the hospital has more and more patients, sitting, waiting to be attended to.

- One small room has at least 25 beds haphazardly squashed into it. Another has only a few centimetres between each bed. It seems that psychiatric patients have been put next to other patients.

- A woman with her leg in a cast had come to the hospital in agony seven hours prior, in an ambulance. The previous month they had cast her leg without having taken an X-ray. At 4.30pm she is told the X-ray department has closed, and she should return the next day. The doctor has not seen her. As she leaves the hospital in a wheelchair, she is still in agony. In her opinion, coming to this hospital is a waste of time.

- Three people struggle to get an unconscious person – who has been discharged – into the back of a car. They use a piece of material to get the person off the trolley, and eventually, onto the back seat. During this 20-minute challenge, cleaners look on.

- An old man, looking gaunt and sick, leaves the hospital. A pulled-down TB mask rests on his neck.

- A hungry man eventually leaves the hospital by getting a lift with strangers. He has been there for eight hours. He has no money for food or for a taxi.

- A white van emblazoned with a “21st Century Funerals” logo stands outside the accident and emergency entrance. A trolley is carried out of the back and taken inside the hospital. A while later the driver returns, pushing a corpse in a body bag past patients entering the hospital in order to load it into the back of the van.

New SANAC CEO responds to questions about his past

By Ufrieda Ho

Dr Sandile Buthelezi was recently appointed as the new head (CEO) of the South African National AIDS Council. His appointment follows the suspicious non-renewal of the previous CEO’s contract Dr Fareed Abdullah and unsuccessful attempts to lure Eastern Cape head of health Dr Thobile Mbengashe to the post. The success of the new National Strategic Plan implementation and the long-term survival of a robust, relevant and ethical SA National AIDS Council will depend on the new CEO. Spotlight put a range of questions to Buthelezi regarding his involvement in the Tara KLamp debacle, the persecution of doctors at Manguzi Hospital in 2008, and allegations of corruption.

Dr Sandile Buthelezi was recently appointed as the new Chief Executive Officer (CEO) of the South African National AIDS Council (SANAC). Buthelezi’s appointment comes as a surprise, given that it was expected that the position would go to Thobile Mbengashe – who Spotlight understood to have been the preferred candidate of key members of the SANAC board of trustees. However, we understand the Eastern Cape made Mbengashe a counter offer, which made it hard for him to leave for the SANAC job.

Buthelezi’s appointment also surprised activists who are concerned about his involvement in the rollout of an unsafe circumcision device (the Tara KLamp) in Kwazulu-Natal and the persecution of doctors at Manguzi Hospital in 2008. The doctors were providing dual antiretroviral therapy to pregnant women with HIV. At the time providing dual therapy was deemed to be against the government policy of AIDS denialist President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang.

Highly charged atmosphere

Buthelezi is stepping into a highly charged atmosphere with recent news reports describing SANAC as being in disarray and various civil society organisations considering a withdrawal from SANAC. Some of the concerns regarding governance at SANAC relate to the process of appointing a new CEO. For reasons that have not yet been explained, an initial recruitment process was stopped halfway and the post was readvertised early this year. In February this year the trustees, then led by Dr Gwen Ramakgopa, who is now Gauteng MEC for health, announced that Dr Malega Constance Kganakga had been appointed acting CEO for three months while interviews were being completed. It would be another four months (after those initial three months) before Buthelezi took office at the beginning of September 2017.

The board controversially decided in February not to extend the CEO contract of Dr Fareed Abdullah or to allow him to continue as interim CEO. This move was met with widespread condemnation from activists and the Democratic Alliance. Abdullah is credited by some for transforming SANAC into an independent Council that for the first time had five straight years of clean audits and better checks and balances in place to ensure good governance.

Buthelezi told Spotlight he wishes to thank his predecessors “for building SANAC into the credible organization that it is”. “SANAC operates against the backdrop of people’s perception of government institutions and hence our first duty will be demonstrating good corporate governance,” says Buthelezi. “This is a critical obligation that we at SANAC need to uphold, and it will be the hallmark of my tenure.

Persecution of Manguzi doctors

In 2008 Buthelezi was head of HIV and AIDS in KwaZulu-Natal where he played a role in the persecution of doctors at Manguzi Hospital. Dr Colin Pfaff, acting medical manager at Manguzi Hospital at the time, and colleagues broke rank from official Department of Health policy to introduce dual-therapy treatment for HIV-positive pregnant women at a time when official government policy was to provide only monotherapy.

The science at the time was clear that dual therapy was superior to monotherapy in reducing mother-to-child transmission of HIV. Pfaff raised funds from donors to pay for the introduction of dual therapy at Manguzi. Pfaff was suspended for this and faced disciplinary action – that was later withdrawn.

Buthelezi admits he worked closely with doctors in the district at the time and adds: “I believe it is unfair to expect a junior official to act out of sync with national government policy.” At the time Buthelezi was quoted making a similar argument in the New York Times saying “I am wary of us undermining national just because of what other provinces are doing (referring to the rollout of dual therapy in the Western Cape)”. At the time Buthelezi was working under controversial KwaZulu-Natal MEC for Health Peggy Nkonyeni – who was a close ally of AIDS denialist Health Minister Dr Manto Tshabalala-Msimang.

No regrets regarding Tara KLamp

In 2010, Two years after the Manguzi scandal, with government-sanctioned AIDS denialism having meanwhile “ended” under the leadership of first Health Minister Barbara Hogan and then her successor Dr Aaron Motsoaledi, the Kwazulu-Natal Department of Health was involved in another high-profile controversy. The department started providing circumcisions with an unsafe plastic circumcision device called the Tara KLamp. The device caused a number of serious injuries and eventually became the subject of a Treatment Action Campaign complaint to the Public Protector. Questions about alleged kickbacks relating to the procurement of the Tara KLamp remain unresolved seven years later.

While Buthelezi wrote letters and was quoted in the media in relation to the Manguzi scandal, it appears he was less directly involved with the Tara KLamp rollout. Another Sandile, Sandile Tshablalala, was in charge of the circumcision programme in the province. As with Manguzi, the Tara KLamp had high-profile political backing  this time in the form of MEC for Health Sibongiseni Dhlomo, then Premier of Kwazulu-Natal Zweli Mkhize, and King Goodwil Zwelithini.

Yet, as head of HIV and AIDS in the province Buthelezi would have almost certainly been party to decisions made regarding the rollout of the Tara KLamp. We can find no evidence that he opposed the rollout in any way – this while he admits involvement in the circumcision programme. “I am proud of my contribution to the roll-out of medical male circumcision in KwaZulu-Natal,” says Buthelezi, wwhich included (…) Rallying all stakeholders including His Majesty, in advocating for MMC.”

“The implementation of medical male circumcision in the province remains a watershed moment in the country’s HIV response,” he says. “A province where circumcision was not routinely practised, took the lead in including medical male circumcision as part of a combined package of prevention methods. This is a significant achievement and I have no regrets.”

Corruption allegations

In late 2010 Buthelezi left the KZN Department of Health. A source suggested to Spotlight that Buthelezi’s departure was related to allegations that he awarded a catering contract to a family member.

While Buthelezi does not dispute that the allegations were made, he insists that they are baseless and untested. “The issue relates to a tender that was dealt with at a district where I was not involved in any of the bid committees,” he says. “I only received paper work to approve payment after the district committees and management had signed that they received the goods and/or services.”

Buthelezi says he left the KZN Department of Health because he received a better job offer and that he continued to have a good relationship with the department after he left. He took up a position as country director of ICAP, a University of Columbia initiative to strengthen health systems around the world. From there he left to work at HLSP- Mott MacDonald, as senior technical lead with the health sector consultancy. In 2014 he was reappointed to the ICAP role.

“He will have to build trust”

Several of Buthelezi’s previous colleagues, members of the SANAC board and people he had professional dealings with at his previous positions were contacted to comment on Buthelezi’s appointment. Some didn’t respond and some declined to comment on record. Professor Wafaa El-Sadr the director of ICAP, based in New York, did comment, saying that in the last three years that he reported to her that Buthelezi did meet specific implementation targets and successfully built important linkages and partnerships within his team. “He had a good understanding of the lay of the land. He had the experience and he did understand South African realities.

“The challenges for a strong SANAC will be about never losing sight of the core of what we do and that is to change the lives of people. He will have to build trust and be able to bring along with him even those people who are not supportive of him,” says El-Sadr.

“He was on the wrong side”

Anele Yawa, General Secretary of the Treatment Action Campaign, says that Buthelezi’s past cannot be ignored. “He was on the wrong side – he was an AIDS denialist, like Manto Tshabalala-Msimang and Thabo Mbeki, he wasn’t for the people,” he says.

“We don’t just want a warm body in the position of CEO and we still don’t know what happened with the process of appointing a new CEO,” says Yawa. “Buthelezi must be able to add value. He can start with audits of the organisations that are part of the SANAC civil society sector – he can even start with TAC, this will make it clear who should be part of SANAC and who should not.”

Yawa says SANAC has to return to the grassroots – the face of HIV/AIDS, not be fixated on “meetings and conferences held in fancy hotels”.

Even with his outspoken criticism, Yawa says that for now TAC remains committed to staying within SANAC. “We want to fix the problems because we have come a long way. But when we ring the bell Buthelezi must come. We give him three months to get his house in order,” says Yawa.

“I believe in service”

Buthelezi says his vision for SANAC will become clearer once he settles into the role. But he says he’s up to the job. “I come from rural eShowe where humility, respect and ubuntu define human relations,” he says. “We’ve fought HIV for too long – we must see results.”

“I believe in service and I am results-driven and work well with teams. I hope we shall be an organisation that listen actively, prioritises what’s important, adapts readily and empowers others.”


TAC survey highlights poor infection control in clinics

By Marcus Low

Tuberculosis (TB) infection control measures in some South African public sector clinics fall woefully short. This is according to an infection control survey that was published by the Treatment Action Campaign (TAC) ahead of World TB Day (23 March 2017).

While the survey has some limitations, and is by no means an exhaustive survey of clinics in South Africa, it nevertheless provides compelling evidence that we have an infection control problem at a number of public sector clinics. Given that poor infection control at clinics may be a significant contributor to TB transmission in South Africa, this is a red flag that should be taken seriously.

How was the survey conducted?

TAC branch members across seven of South Africa’s nine provinces were trained on a TB infection control questionnaire. Delegations from TAC branches then went to their local clinics to fill in the questionnaire. They reported their findings back to the TAC national office where the findings were captured.

The questionnaire contained seven questions relating to TB infection control measures that should be in place at clinics. Each question was simply given a “yes” or “no” answer. It was designed in such a way that “yes” answers in each case indicated correct infection control procedures. In other words, the more “yes” answers a clinic got, the better.

What did the survey find?

As part of their media release, TAC published an Excel file with the data they collected. This file contains details of the 158 clinics that were surveyed and how each of seven questions were answered in relation to these clinics. Below we present some additional analysis we conducted of the data provided by TAC. (For those interested in exploring the data, we have done some data cleaning and saved it as a CSV file that can be downloaded here.)

While TAC rated each clinic red, orange, or green – the data can also be represented as a score out of 7 for each clinic – where each yes answer adds 1 point to the score. Thus clinics that score 7/7 are rated green, 5/7 or 6/7 are rated orange, and 4/7 or less are rated red.

Scores by province

ProvinceNumber of clinics surveyedMean score out of 7
Western Cape 15 4.67
Eastern Cape253.52
Free State193.16

The above table shows the mean score of the clinics surveyed in each province. We should stress though that these are not representative samples and the findings cannot be generalised to entire provinces. The mean scores in some provinces are also so close together that we should not read anything into the fact that e.g. Mpumalanga is above Gauteng, or that Free State is above Limpopo. It does seem significant however that the clinics that were surveyed in the Western Cape tended to do substantially better than clinics surveyed in other provinces.

No clinics in the North West province and the Northern Cape were surveyed. Of the seven provinces surveyed, Mpumalanga is somewhat over-represented with 39 out of the 158 clinics – most other provinces had around 20 clinics surveyed.

Results by question

This table shows the total NO and YES answers to the seven questions. In each case YES indicates correct infection control measures. Only question 1 and 3 received more than 50% YES answers. Question 5 received exactly 50% YES answers.

QuestionsAnswered NOAnswered YES
1. Are the windows open?22136
2. Is there enough room in the waiting area?9266
3. Are there posters telling you to cover your mouth when coughing or sneezing?6494
4. Are you seen within 30 minutes of arriving at the clinic?10157
5. Are people in the clinic waiting area asked if they have TB symptoms? 7979
6. Are people who are coughing separated from those who are not?10553
7. Are people who cough a lot or who may have TB given tissues or TB masks?11642

The TB infection control measure on which clinics did the best was keeping the windows open in the waiting area. Second best was having posters up on the walls telling people to cover their mouths when coughing or sneezing. However, apart from opening windows and having posters on the walls most clinics did very poorly at TB infection control.

It is also notable that on the cross-cutting question as to whether people are seen within 30 minutes, only 57 of the 158 clinics got “yes” answers. Long waiting times becomes a more important risk factor when other infection control measures are not in place because people are exposed for longer periods. The mean score in clinics with less than 30-minute waiting times was 5.1 compared to only 2.3 in clinics with longer waiting times – in other words, the clinics where people waited longer tended to be clinics where the risk of TB infection were already substantially higher.

How much did clinic scores vary?

Only 15 of the 158 clinics in the survey got “green” ratings. 31 were rated “orange” and 112 were rated “red”. The mean rating for all clinics surveyed was 3.34/7 and the median was 3/7.