#Vote4Health: Seven years of struggle at Holy Cross Hospital

By Kathryn Cleary and Zizo Zikali

The main entrance to Holy Cross Hospital, 23km from the centre of Flagstaff, Eastern Cape.

The long-suffering Holy Cross Hospital outside Flagstaff, Eastern Cape, has a troubling history. The hospital services eleven traditional houses, (roughly 100 villages) in the Ingquza Hill Local Municipality, part of the OR Tambo District. As part of the #Vote4Health series, Spotlight and Health-e News re-visited the hospital after years of turmoil. The visit follows NSP Review’s harrowing 2013 ‘Death and Dying’ report – as well as drastic water shortages, near collapse of the hospital and numerous government interventions.

While Holy Cross hospital has a longer history, our timeline starts in January 2012 as a R105 million refurbishment of the hospital is completed. The refurbishment forms part of the broader Department of Health Hospital Revitalisation Programme.

January 2012, refurbishment of Holy Cross Hospital finishes.

13 September 2013, NSP Review, a Section27 and Treatment Action Campaign (TAC) publication (now known as Spotlight), publishes a comprehensive report titled “Death and Dying in the Eastern Cape.” The report details heartbreaking accounts of poor service delivery in the Eastern Cape’s public health sector. One story, Baby Ikho: He should have lived, tells the story of a toddler’s final hours in Holy Cross Hospital after being admitted with a chest infection. With oxygen needed to save his life, the story recalls the attending doctor, Dr Dingeman Rijken, tearfully watching, helpless, as  the last few ounces of oxygen in the hospital ran out, leaving Ikho gasping for air, and eventually passing away. Baby Ikho’s story was read by many, including some at the Department of Health, the Health Professions Council of South Africa (HPCSA) and the Office of Health Standards and Compliance (OHSC). The story was later redacted in the published version of the report to permit further investigation by the National Department of Health.

19 September 2013, Minister of Health Aaron Motsoaledi responds publicly to the report. In a media briefing Motsoaledi confirms that the Department was aware of the challenges faced by the Eastern Cape; particularly the deplorable state of public healthcare services in the OR Tambo District. The report prompted an urgent investigation by the National Department of Health. The investigative team’s findings included gross shortages of vital medical equipment in the maternal ward, including an absence of fetal heart monitors and thermometers; poor staff attitudes towards patients and other staff, as well as poor management and financial corruption.

Motsoaledi recommended that the CEO and Nursing Services Manager be suspended and put under investigation immediately, and for the Hospital Administrator to be investigated. Further, he urged that the CEO and Nursing Services Manager be reported to the South African Nursing Council (SANC).

Additional recommendations included a forensic audit of the hospital and an intervention at the District level. Vital medical equipment was also to be purchased and distributed to Holy Cross as well as 13 District, 2 Regional and 3 Specialised hospitals in OR Tambo. This was scheduled to occur the week after the media briefing, 23 September 2013.

2014, the OHSC issues an inspection report scoring Holy Cross Hospital at 43 percent, a failing score.

21 October 2015, Spotlight publishes a follow-up story titled “Holy Cross: Some progress, but all is not well”. The article highlights the devastating water shortages at the hospital, lasting at times for over a week. A Doctor quoted in the story recalled a water outage for six weeks; having dire consequences for patients and staff.

Other issues included staff accommodation, staff shortages, a lack of permanent staff and a faulty top-down management system. A source in the story claimed that the centralisation of the provincial management system was inefficient, and that sending paperwork off to Mthatha for signatures was impractical.

2016 the OHSC scores Holy Cross Hospital at 60 percent. While still below the OHSC pass level of 80 percent it is nevertheless a marked improvement from 2014.

2016-2017, the OHSC issues another inspection report rating the Eastern Cape at 43 percent, and Eastern Cape hospitals at 50 percent. Nationally, the Eastern Cape had the lowest score.

January 2017, Holy Cross residents take their frustrations to the streets demanding improved health services at the hospital. Residents barricade the road linking the hospital to the R61 with burning tyres; everything was brought to a stand-still, including ambulances and patient transport vehicles.

The leader of the strike, Dumisani Mbangatha states that grievances included long queues, poor staff attitudes, a shortage of medicine (as a result patients were sent home without their medication), and nepotism.

Mbangatha and residents also demand that (now former) CEO Gloria Mazeka should be removed from her position.

Mbangatha added that according to the hospital’s organogram, the Board of Directors was to report to the community, however there were no open lines of communication between the Board and the community.

In response to community uproar (now former) MEC Dr Pumza Dyantyi visited the hospital. Dyantyi received a memorandum from the community and asked a task team to further investigate allegations.

6 April 2017, MEC Dr Pumza Dyantyi returns to Holy Cross to receive the task team report.

10 April 2017, In an article titled ‘The hell suffered by patients at Holy Cross Hospital’, Health-e reports that the water crisis and other issues at Holy Cross are far from over.

August 2017, Holy Cross Hospital NEHAWU Chairperson Mthandwa Zitha says that the functionality of the hospital had been compromised due to a lack of non-permanent senior management officials. At the time, Holy Cross had only an Acting Hospital Administrator, and critical posts such as Chief Medical Officer and Nursing Services Manager were vacant. Zitha recommended that a situational analysis be conducted concerning the high rate of staff turnover at the hospital.

Adding to this, the hospital’s DENOSA Chairperson Mzolisi Ludumo, said the issue of vacant positions in management is not a challenge solely faced by Holy Cross, but that District hospitals such as Holy Cross, St Patrick’s and Grenville experienced similar challenges in human resources.

December 2017, Health-e reports that soon nurses at Holy Cross could be left without accommodation. Nurses residing in trust houses (used as nurses homes) were notified to vacate the properties before 2 January 2018, the eviction notice was from the Anglican Church Authorities who claimed that the land on which the nurses’ homes were situated was owned by the church. The then Anglican Bishop Thanduxolo Magadla claimed that they wanted to renovate the buildings to create decent accommodation for the nurses who in turn would pay rentals to the church.

According to former hospital board chairperson Mthuthuzeli Sinukela, the eviction process was unpleasant and nurses complained of harassment during the process.

February 2019, Health-e further reports that there was a dispute about the rightful owners of the land where the trust houses are located; the dispute was between NEHAWU, the Anglican Church, the traditional leaders and the community.

The community claimed that the hospital land belonged to the community, while the traditional leaders said the church is the rightful owner have a title deed to prove it. However, NEHAWU Chairperson Mthanndwa Zitha claimed that the houses were built by the Department of Health many years ago to accommodate hospital staff.

Ingquza Hill Traditional Council Thandisizwe Mgwili confirmed that the rightful owner of the hospital land is the church.

April 2019, a copy of the 2017 investigative task team report is requested from the Eastern Cape Department of Health. Failing to respond to queries from Spotlight, a PAIA request for the document was later submitted on 9 April.

In April 2019 Spotlight and Health-e also publishes a new article on the situation at Holy Cross and a timeline of events at the hospital over the last seven years (the document you are now reading).


#Vote4Health: More than a bucket and a plaster to fix rural healthcare

By Kathryn Cleary and Zizo Zikali

The rolling hills and valleys surrounding Holy Cross Hospital make transport to the hospital a challenge for residents. There is a critical reliance on local taxis and other public transportation. Photo: Kathryn Cleary, Spotlight

As the seasons change and summer becomes a more distant memory, May elections creep closer and closer for the country. Campaign posters line the roadways and fight for space on telephone poles of every city and village. While citizens gear up to cast their votes, some lie in hospital waiting areas hour after hour in dire need of quality care. For some, a trip to the hospital may seem like a breeze, but for others, particularly in the rural Eastern Cape, a hospital visit can be a herculean task.

Despite years of intervention at Holy Cross Hospital in Flagstaff, Eastern Cape, there is still a long way to go. Though government emergency interventions have made some impact, for Holy Cross a much more permanent solution is needed. Interventions in 2013 and 2017 have created a plaster over the issues, but the single bucket filled with water in the hospital’s waiting area tells a different story. Holy Cross Hospital highlights the systemic failures of the rural public healthcare system – it will take much more than a bucket and a plaster to fix.

8pm, a yellow Sunfoil bucket filled with water sits in the corner of the main waiting area of Holy Cross Hospital. There appears to be two cups on top of the bucket for patients, visitors and waiting families to use to drink. Spotlight and Health-e were informed of this ‘bucket system’ by a patient earlier in the day outside of the hospital grounds.

Ahead of the 2019 elections, Spotlight and Health-e journalists worked together to see if anything had really changed at the hospital after the interventions in 2013 and 2017. Although our journalists were denied permission to formally visit the hospital by the Department of Health; patients and community members outside the hospital premises were willing to speak.

The main entrance to Holy Cross Hospital, 23km from the centre of Flagstaff, Eastern Cape. The road to the hospital is smooth tar; wrapping around hillsides and down steep valleys of rural Transkei. The entrance is frequented by taxis constantly dropping off and picking up prospective patients and families.

Sizakele Theophilus Hlongwana is the local Ward Councillor; residents within his ward were behind protest action in 2017 which lead to an intervention by the MEC. “Post 2017 community strike there has been a slight change”, said Hlongwana. “Waiting hours have been reduced depending which day of the week it is.”

One patient told Health-e that there must be a shortage of beds at the hospital because patients were forced to sleep on benches in the waiting area.

Ntuthuzelo Maganya of Mtshayelo Village had a serious head injury in January of this year and was rushed to hospital.

“On arrival I was put on a drip and told to move from the bed to a bench so that a patient who is sicker could have the bed.”

“I stayed there all night waiting for the doctor who arrived around 7 am. The doctor attended to me and transferred me to Nelson Mandela Hospital, I slept for the second night on the bench while I was waiting for an ambulance to Mthatha.”

Maganya was not the only person to complain about a shortage of beds and sleeping on benches. During an evening visit to the hospital several families were spreading blankets out on the floor in order to sleep, anxiously waiting for ambulances and transport vehicles to Mthatha. Mthatha is over 160kms away, almost 3 hours on steep winding roads.

One family declined to speak, fearing they would lose their spot on the next available ambulance.

A patient transport vehicle arrived at the hospital by 8:30pm that evening, dropping off a full load of patients and their family members.

A birds-eye view of Holy Cross Hospital, 23km from the centre of Flagstaff, Eastern Cape. Spotlight and Health-e were denied permission to visit the hospital by the Department of Health. Photo: Kathryn Cleary, Spotlight

After numerous attempts, the Department of Health failed to respond to questions from Spotlight and Health-e; the questions were directed to the hospital’s current CEO and queried staff shortages and vacancies, water and infrastructure issues, the ongoing investigation of the Hospital Board, and the outcome and recommendations of a 2017 task team report into Holy Cross Hospital.

The Department of Health did not provide the task team report to media, as a result Spotlight has filed a PAIA request to obtain access to the document.

Small improvements since 2017

A NEHAWU leader at the hospital said there had been improvement at the hospital since the MEC’s intervention in 2017. Former MEC Dr Pumza Dyantyi intervened after disruptive protests at the hospital in 2017 and appointed a task team – it is that task team’s report we have not been given access to.

“Generally [things] are better in terms of assistance from the Bhisho offices, but in terms of the District it is still the same. If you look at systems, they are too centralised.”

The source said they received the report last December, and the hospital had implemented the majority of the recommendations. They added that management had improved under a new CEO as well as patient care, but transport and ambulance services remained a critical issue.

Due to a lack of specialist doctors, many Holy Cross patients are referred to Nelson Mandela Academic Hospital in Mthatha.

“The issue is that most specialised local doctors don’t want to work here”, they said. “I can’t say the actual cause”.

The Department of Health was queried as to how many vacancies and resignations the hospital had within the last year, but no response was provided.

Another issue emphasised by the NEHAWU Chairperson was the crumbling infrastructure of the hospital; attributing it to burst water pipes. The source confirmed that the bucket of water in the hospital’s waiting area was a reality, and that while some wards had aqua coolers for drinking water, others were without. These complaints follow a major R105 million refurbishment of the hospital completed in January 2012.

Insights into the 2017 task team report

Echoing the sentiments of NEHAWU, a source from the Hospital Board provided more insight into the 2017 task team’s report.

“I can assure you, since after the toyi-toyi, we tried to respond to all of the things that were part of the report by the task team.”, said Aubrey Ruleni, Chairperson of the Holy Cross Hospital Board.

Ruleni said that the recommendations made in the report were implemented to the best of the hospital’s ability; changes were made in management and the Hospital Board.

“We are trying our best”, he said.

“One of the things raised in that report was that the Hospital Board doesn’t go to people [in the community], so as a result people lack information. We needed to address that and we did.”

Following the 2017 intervention the Hospital Board was put under investigation, according to Ruleni this is still ongoing.

Ruleni added that the CEO at the time of the 2017 protests had been removed. “The CEO ultimately left the hospital, [they were] taken by the Department to another hospital. According to the findings, nothing was done wrong by the CEO, it was [community] allegations and those allegations were not proved positive.”

Ruleni stated that he was unaware of any incident where a doctor had resigned or transferred as a result of mismanagement or poor treatment.

“The problem we have [is that] some doctors don’t want to stay for a long time in the rural areas. Sometimes it’s not because there is a problem with the hospital, but maybe because they do not enjoy being in the rural areas,” Ruleni said. “The issue of doctors, they come and they go, it’s not a new thing and it’s happening to all hospitals.”

Regarding emergency medical services in the Flagstaff area, Ruleni said that the closest ambulance service was 60km away in Mount Ayliff. The lack of EMS in rural areas of the Eastern Cape has been reported on in depth by Spotlight and Section27.

“We are striving, trying our best to solve that [and] to have our own resources.”, said Ruleni. “Because at the end of the day we don’t know what’s going to happen, [and] when. That is a problem.”

Ruleni emphasised frustration with supply chain management in the province; stating that it was a challenge for paperwork to go through Bhisho nearly 6 hours away, when there are qualified people in the local area capable of doing the work.

“We are still trying to engage the Department to assist us.”, he said.

Holy Cross and the NHI

Thinking forward about the proposed National Health Insurance (NHI), Ruleni says that it cannot be properly executed at Holy Cross unless basic infrastructure is upgraded.

“The problem of water at Holy Cross Hospital is caused by the old pipes. Anytime, I can get a call that there is a burst pipe. We are trying to sensitise the Department about that.”

“We really welcome NHI, but the infrastructure must be upgraded. When we talk about the NHI, you are talking about the issue of those people who cannot afford to have medical aid. If the situation is as it is now, I don’t think it’s going to work.”

Like many other rural hospitals, without improved infrastructure and supply chain management, the NHI remains a pipe dream.

“As much as I welcome it as a good idea, in the rural areas we are still having challenges.”, said Ruleni.

“I would like to see Holy Cross Hospital stand on its own, [and] not be managed by somebody in a certain corner. Also, we would like to see the people around the area to support whatever initiatives.”

“Sometimes the people are vandalising even the fencing, so if the people can assist us to stop [that from happening]. If they assist us, Holy Cross is moving in the right direction.”

A sign points to Holy Cross Hospital, a right turn takes residents uphill on a tar road leading to the main entrance. Photo: Kathryn Cleary, Spotlight

*Kathryn Cleary is a health journalist with Grocott’s Mail in Makhanda, Eastern Cape and was commissioned by Spotlight to write this article.

*Zizo Zikali is a citizen journalist with Health-e News and is based in Flagstaff.

#Vote4Health: New hope as Lusikisiki finally gets a new clinic

Article by Biénne Huisman

Photographs by Halden Krog

In Lusikisiki, in the OR Tambo District of the Eastern Cape, the so-called Village Clinic had become emblematic of a faltering health system, in a rural area fraught with chronic illness and early death due to rapidly-spreading HIV and tuberculosis. Now, following years of activism and litigation that started in 2013, a new state-of-the-art incarnation of the clinic is finally poised for official opening on April 3.

Lusikisiki, formerly the capital of Eastern Pondoland, consists of a bustling commercial centre and roughly 40 villages scattered across a 60-kilometre radius flanking the sea. The area is a significant health strategy node in that from 2002 to 2005 it served as South Africa’s first rural antiretroviral rollout base, a programme spearheaded by international nongovernmental organisation Médecins Sans Frontières (MSF), (Doctors Without Borders). It was also decreed one of South Africa’s 10 National Health Insurance pilot sites in 2012.

Eastern Cape department of health spokesperson Lwandile Sicwetsha did not respond to calls or messages from Spotlight requesting information on the new Village Clinic.

However, national department of health spokesperson Popo Maja confirmed that President Cyril Ramaphosa will headline the facility’s April inauguration, with health minister Dr Aaron Motsoaledi also in attendance.

Failed attempts to engage with Eastern Cape health officials is perhaps not surprising.

In May 2013 the Treatment Action Campaign (TAC) filed a lawsuit against the Eastern Cape’s health department for failing to address dire conditions at Village Clinic, then housed in two tents and a rickety park home on a muddy plot without electricity, and with just one pit latrine on a steep embankment. At the time, witnesses noted how one of the clinic’s nurses broke an arm climbing up to the toilet.

In their 2013 court papers, the TAC listed Motsoaledi as a respondent. In his response Motsoaledi agreed that circumstances at the clinic were unacceptable –sidelining the provincial health department to arrange for the erection of a temporary structure to house the clinic, while tabling plans for an entirely new building. This is the facility finally set to launch next month, after more than five years of setbacks and delays.

In February, Spotlight visited Lusikisiki’s new Village Clinic, which sprawls impressively across a quiet block set back from the town’s teeming main road. The premises already opened its doors to patients in September last year.

The clinic sits behind ample parking and a high fence, with a gentle sloping ramp for wheelchair access. At its entrance, two security guards smile in greeting, pointing towards reception.

Inside, along the first corridor, doors are marked: dental surgery, oral hygienist room, emergency room, and manager’s office, along with three consulting rooms and a counselling room. The consulting rooms are fitted with brand new examination beds, with step access, wall-mounted examining lights, and electronic blood monitoring equipment; on desks there are boxes of hypodermic needles and Vitamin B injections.

In the corridor, two teenage boys in school uniform are waiting to pick up medicine during their school break. ‘We came here for an injection for my friend, you see he has the scabies disease,’ says one boy. ‘We waited 30 minutes to get the injection. This is not bad; at the old clinic it would have taken much longer, we would have had to sit in the sun all day. It got very hot waiting at that clinic, it was very hectic actually.’ His friend attests: ’Yes this is way better.’ Ambling away, he adds: ’So we’re going to the pharmacy now, to get the medication the nurse wrote down.’

Indeed, inside the complex is a dispensary, where a pharmacist in a white coat serves patients one by one from behind a glass pane.

In front of the dispensary is a waiting area, with 82 people – many with babies huddled to their chests – seated in rows on metal benches. To the side in a playroom, parents are watching hip-high toddlers waddling over artificial grass; a man is tilting yoghurt into an infant’s mouth.

Sitting in the waiting area is 25-year-old Nkani Sinelizwi from New Rest location, about a kilometre from the clinic. He pulls up his trouser leg to show a bandaged ankle; he was bitten by a dog the previous Friday, and is waiting for his second tetanus shot. ‘For the first injection I waited 20 minutes, this is a big improvement on the service we had before,’ says Sinelizwi. He is a psychology student interested in mental disorders. ‘People here struggle to differentiate between mental disorders and witchcraft,’ he says. ‘I want to help teach them to differentiate.’

Overhead, the ceiling is high and the air remarkably cool, given the stifling heat outside.

There is a low hum of voices, punctuated by a baby’s shrieks from the maternity section on the building’s far side.

In a consulting room adjacent to the maternity section, nursing assistant Princess Dlakavu is seeing patients. A resident of the Dubana AA location – near the Lusikisiki prison – she is 58 years old and has worked at the Village Clinic for about twenty years, she says.

Dlakavu’s eyes are bright as she points at the equipment around her.

‘Yes at the previous clinic there were challenges. There was no space, but we tried. There were high statistics, HIV, a lot of patients. But now we have many, many consulting rooms.’ She pauses to count: ‘Fourteen consulting rooms in total, yes that’s a lot. Then there is the dental facility, the emergency room, the maternity ward, and the section for chronic illnesses; that’s for our diabetic, hypertensive, and psychological patients, and people who need ARVs, people with TB.’

Dlakavu worked at the Village Clinic when MSF doctor Hermann Reuter brought ARV medication there – and to 11 other clinics around Lusikisiki – in partnership with the Eastern Cape Department of Health. In his book Three Letter Plague, Jonny Steinberg notes that when MSF arrived in Lusikisiki in 2002, one in three pregnant women tested positive for HIV. Reuter’s driving passion was to destigmatise HIV testing and treatment.

Dlakavu recalls: ‘He [Reuter] educated people about the ARVs very well; he taught us about the support groups, that people must be free to tell each other that they are sick, and that they must be free to talk about the side-effects.’

She says that after MSF left in 2005, clinics in the area continued with the programme.

Today, talk on the street is that ARVs are readily available.

Outside the Village Clinic, a 29-year-old woman looks relaxed while speaking to Spotlight. She says many of her generation have realised that ARVs bring about quality of life.

‘Now the most people are taking ARVs,’ she says. ’In the past, if I was going to pick up ARVs, and I saw someone I knew, I would hide myself. Because I would not want them to know my status, that is if I’m HIV positive. But now, most of the people are just going to get their medicine.’

She adds that waiting time to pick up treatment is minimal: ‘When you pick up ARVs there are no queues. You just take out your card – a medical card that shows what you are having – and you give it to the person that’s helping you, and you get your treatment and you go home. Unless it’s your first time, then it’s going to take a little bit more time.’

At the TAC offices flanking Lusikisiki’s Magistrates Court, the TAC’s long-time provincial manager, Noloyiso Ntamenthlo, agrees that ARVs are today widely accessible in the region. However, Ntamenthlo voices concern over the unavailability of other medicines required to treat HIV-related symptoms: ’The challenge is the unavailability of other drugs. I mean, say for example I’m living with HIV and I have shingles; if I’m living with HIV and I have diarrhoea. So in our clinics we are struggling to access these essential medicines; especially in the OR Tambo region, here in Lusikisiki. I was presenting this problem to the MEC [Eastern Cape health MEC Helen Sauls-August] saying that we are struggling. The MEC then said they are doing renovations at the depot in Mthatha, and that everything’s upside down. My point is, what was their plan? You can’t just renovate without considering that people are going to suffer without this medicine, it’s very difficult.’

In addition, Ntamenthlo notes that other clinics in the area are in desperate need of upgrades, notably the one in Flagstaff, 42 kilometres from Lusikisiki’s town centre along the winding R61. ‘The Flagstaff Clinic is incomplete,’ she says. ‘The clinic is operating from the old post office container. At the clinic, when the sisters want a urine sample, the patients and the pregnant women have to go outside to the grass to pee, and then return with the urine. So there are those difficulties.’

Another challenge is the attitudes of clinic staff. Sometimes they treat patients known to them ahead of others who have waited longer; or they insult patients. ‘There are the insults from nurses and staff supposed to help you: ‘You are smelly, go wash your body.’ Maybe that person is sick or staying at home alone and there is no one to assist with cleaning,’ says Ntamenthlo.

Regarding the new Village Clinic, Ntamenthlo is raising questions over the medical staff required to operate the facility.

‘It’s a beautiful building, the TAC and SECTION27 fought hard for this clinic, I am very happy about it,’ she says. ‘But my problem for that clinic is the issue of human resources. I’m scared the Department of Health does not have a human resource plan, and that is the disaster. They are saying it is the biggest clinic in the province, so where is the staff?’

Meanwhile, at his refreshment table next to the new Village Clinic, Lwazi Deyi, of Palmerton village, 10 kilometres away, reports a drop in business. ’I had a shop at the old clinic on the other side as well,’ says Deyi. ’Business was better that side, because people stood outside in the sun and rain waiting for hours, so they would buy my products while waiting. But yes, I decided to follow the new clinic to this side.’

Underneath a blue umbrella his wares are on display: apples, bananas, vetkoek, and chilli sausages.

‘I am selling healthy things, as you can see,’ he says. ‘I look after the patients and want them to get well soon. These are my people, I don’t want them to be sick or to die. I am very happy about the new building.’

All in all, in the days leading up to its official opening, the new Village Clinic is shrouded in an atmosphere of optimism. On the faces of most of those walking its corridors and precincts, looks of cautious wonder; a glow of pride and dignity.

Note: Huisman is a writer and freelance journalist. She was commissioned by Spotlight to write this article. While Spotlight is published by SECTION27 and the Treatment Action Campaign, its editors have full editorial independence — independence that the editors guard jealously. Spotlight is a member of the South African Press Council.


Vote4Health: Artist colony paints dull picture for rural healthcare

Hamburg is a small rural community in the Eastern Cape. Home to the Keiskamma Trust, an internationally recognised art, music, education and health NGO. The community is filled with talented artists and colourful displays. Photo: Kathryn Cleary

By Kathryn Cleary

Hamburg in the Eastern Cape, sits tucked away between the Keiskamma River and Indian Ocean coastline. About half way between Port Alfred and East London in the Amathole District, the village filled with artists paints a lacklustre picture of primary healthcare in rural areas. With less than 2 000 residents, one small government clinic and the nearest hospital 40 kilometres away, residents are under strain.

In 2013 Spotlight (then NSP Review) published Death & Dying in the Eastern Cape which among others highlighted the dire state of Hamburg Clinic. In 2017 Spotlight reported that the Hamburg Clinic had been in a dismal state since 2012, and after five years of negotiations, the Department of Health agreed to re-build. The project was scheduled to be completed within a year. Spotlight re-visited the community recently.

Veronica Betani, Supervisor Keiskamma Trust
“The clinic was not here at first. It was up the hill, the things affecting people to go there was the distance. For someone like me, who is fresh and walking upright you can spend half an hour. Elderly people you had to hire a care

Veronica Betani has lived in Hamburg since 2000, and works as a seamstress and supervisor at the Keiskamma Trust; an internationally known non-governmental organisation with programmes in art, music, education and health.

Betani estimated that the old government clinic closed down four years ago; as well as an HIV/AIDS hospice centre that was managed by the Keiskamma Trust. There was a big cry from the community when it closed, because we don’t have the money to take to hospital. We don’t have transport.”

While Nompumelelo Hospital in Peddie is 40 kilometres away, Frere and Cecilia Makiwane in East London are just under 100 kilometres.

Currently the Trust has two vehicles that are used for transport to hospitals at no cost to residents. Betani stated that this service has been operating for more than 10 years. Unless residents have a private car or money for a taxi, these vehicles are the only option.

Betani has little faith in provincial emergency medical services (EMS); and with the Eastern Cape reportedly experiencing a shortage of ambulances, the odds of one travelling 15 kilometres off the R-72 on a gravel road to Hamburg, are generally not in the community’s favour.

Carol Hofmeyr, Founder of the Keiskamma Trust and general practitioner, knows the community’s health background well. Starting in 2000 Hofmeyr worked in Hamburg in response to the HIV/AIDS crisis before antiretrovirals (ARVs) were widely available. With funding from the Trust, the organisation was able to purchase ARVs for the community.

“We were the only people with ARVs”, recalled Hofmeyr. “Even Port Elizabeth and East London didn’t have. But when the government system got in place after (then President) Mbeki left, then the government health service started providing everything.”

Two sides to the same story

In 2017, the government clinic relocated to a Keiskamma Trust building, next to the new building.

It is a small space of only a few makeshift examination rooms, meeting room and  a cramped waiting area that might comfortably sit 10 people. At the time Spotlight visited, a small group of school children were waiting patiently, and nursing staff were hurrying off to a meeting.

Cebo Mvubu, Manager of Keiskamma Art Project
“There is hope that when [the clinic] is built it will have more nurses. I would love to see the service, not the building.” Photo: Kathryn Cleary
A source at the clinic spoke briefly to Spotlight under anonymity, stating, that everything was fine at the clinic, something other sources would later contradict.

The source said that the clinic saw about 700 patients with no issues of patient management or the supply of stock. “When we are out of stock, we order”, they said. The source added that TB infections appeared to be on the decline, with only seven reported cases in 2018 and one so far for 2019.

The source said that the new clinic building was to be opened in May.

Eastern Cape Department of Health Spokesperson, Lwandile Sicwetsha, told Spotlight that the new clinic was complete but could not be opened due to outstanding water connections. “Our infrastructure department is working on resolving this matter with the municipality. It will only be opened when the water connection has been done.”, said Sicwetsha.

“We were so happy to know that by 2019 we were going to have a clinic but we are still waiting for them to open.”, said Betani.

Betani added that frequently the clinic was out of certain medications, another resident said the same, with two of her family members in need of medication on a monthly basis.

These two rondavels served as a birth centre from 2017; the only service of it’s kind in Hamburg. Due to water shortages from September 2018 through February of this year, women have not been able to use the centre. As a result, the centre tried to offer door to door services but could not manage due to poor privacy and sanitation conditions in rural homes. A new birth house is currently under construction. Maternal health is one of many gaps in primary healthcare services for rural Eastern Cape communities. Photo: Kathryn Cleary

Marionette Coetzee is a pensioner in Hamburg that lives with her husband and elderly mother; both need chronic medication on a monthly basis that Coetzee can rarely receive from the clinic alone. Coetzee has no transport and often uses a taxi to East London for specialist appointments and additional medication.

One of Marionette Coetzee’s medication lists; the X marks an item she could not get from the Hamburg Clinic. Photo: Kathryn Cleary

Due to her family members’ limited mobility, Coetzee visits the Hamburg Clinic and East London hospitals alone.

“You will be there at (the clinic) seven in the morning and there’s already benches of people. You will not walk out there before half past four in the afternoon. You will sit there the whole day, sometimes it’s just ridiculous.”

Coetzee showed Spotlight a collection of medication lists that she takes to the clinic each month for her family; from month to month there were clear inconsistencies in the availability of each drug. According to Coetzee’s list, on 21 January the clinic was out of drugs including Tramadol, a common narcotic painkiller, Ventolin solution for asthma, and Diazepam for anxiety.

Coetzee also alleged that a nurse at the Hamburg Clinic is often drunk and smells of alcohol, she was not the only resident that expressed this concern.

Zukiswa Nduli* is a mother in Hamburg, and stays in a small home on the hillside with her children. “We’ve got a challenge with the [one] nurse working there, the problem is [they] are always drunk even if [they] come to the clinic.”

Sicwetsha said the department was aware of the incident and the matter had been referred to the internal employee wellness programme.

Nduli* added that although the current clinic’s location was closer, the services had not improved.

“It’s worse”, she urged. “When we are going to the clinic there is no privacy, even if they try to check if you are pregnant or HIV positive, they can’t keep the secret. They talk to everyone about your health.”

Thinking rural for the NHI

With elections quickly approaching, the proposed National Health Insurance (NHI) system remains a hot topic, particularly for rural areas. Nduli* had not even heard of the NHI, and other residents who were questioned on how it would affect them.

Rural Health Advocacy Project Director, Russell Rensburg, told Spotlight that the NHI was an opportunity for reform in the healthcare system. He described the current system as “out of balance”, filled with issues of management and accountability. Though rural residents will not see results immediately, Rensburg believed the NHI was a step in the right direction.

Sicwetsha stated the Eastern Cape’s NHI pilot project has been tested in rural areas of Alfred Nzo and OR Tambo Districts. “The department is leveraging on these lessons to other areas of the Province.”

Looking forward, future plans for development of the Eastern Cape’s rural healthcare system are under wraps. Sicwetsha said that “plans for the year will be unveiled during the tabling of policy speeches and strategic documents (Annual Performance Plans, Operational Plans and Strategic Plans).” In the meantime, Sicwetsha stated that the department had partnered with the Keiskamma Trust to ensure outreach services continue in Hamburg and surrounding areas.

*Names have been changed to protect the identity of the source

**Read more of Rensburg’s critique of the 2019 healthcare budget and NHI here

Kathryn Cleary is a health journalist with Grocott’s Mail in Makhanda, Eastern Cape and was commissioned by Spotlight to write this article.

Mankosi Clinic: The long and winding road to rural healthcare

By Kathryn Cleary

About 15 km east of Mthatha in the rural Eastern Cape is the Coffee Bay turn-off; a good tar road with busy petrol stations, shops and businesses.

After 70 km further on the smooth tar road take a left onto a narrow winding gravel road. Be wary of the Transkei Big 5 (dogs, sheep, cattle, donkeys, pigs) and the car while driving. Cross the bridge over the Mthatha River and climb up steep hillsides speckled with colourful huts and grazing livestock. After about 30 minutes take a right at a T-junction, and follow the signs for Mdumbi.

Mdumbi village is right on the coastline and is home to the Mdumbi Backpackers; a place frequented by ‘off the beaten path’ travellers. Mankosi village is about 3 km inland from Mdumbi.

After driving up and over a steep hill, a large white building sits on top of a hill just on the right. Red and blue lettering spell “Mankosi Clinic”. There are no cars outside the building, nor any sign of prospective patients one would expect to see at a clinic. The bright lettering and building should be a beacon of hope for this community, but now serves as an obnoxious reminder of broken promises.

A community for its own future

Nowayitile Nyakombi,
Mankosi Community Member: “From the beginning when we had an idea of building this clinic we had a big vision of seeing this clinic operating. Having nurses, nurses that will be based here all the time like 24 hours. So if there is anything that is happening they can quickly rush to the clinic, that is what I want to see.”

Siphokazi Dyantyi* is 25 years old, and has lived in Mankosi village her entire life. Dyantyi* told Spotlight that in 2010 the community came together to build its own clinic, “simply because of the distances that they travel to the nearest clinic.” Along with support from Dutch funders and a local NGO called Transcape, Mankosi sold sand to raise money to build the clinic.

“Mankosi community is very independent”, she said. “It’s a community building its own future.”

Dyantyi* estimated that roughly 3 000 people lived in the village, part of the OR Tambo District.

A mobile government clinic visits Mankosi once per month, but residents say the services provided are not enough.

The Pilani Clinic is 7 km back on the winding gravel road, Dyantyi* estimated it can take up to three hours to walk there, and the closest hospital, Canzibe, is roughly 30 km away. Dyantyi stated that the only public transport residents have to these facilities is a bus that leaves at 5am, and most residents then walk back.

There are no ambulances that service Mankosi, and with few residents owning vehicles, accessing these health facilities can be a nightmare.

Sibongile Masiso was born and raised in Mankosi and now works at the Mdumbi Backpackers. Since 2003, Masiso has been driving community members to and from clinics and hospitals as a result of no EMS services. Masiso keeps track of his call-outs in a small book.

One resident has taken the community’s plight into his own hands. After a cholera outbreak in 2003, Sibongile Masiso took it upon himself to drive community members to the hospital at low-cost. Dyantyi* said that hiring a private vehicle can cost up to R800 one-way, while Masiso’s service is significantly more affordable.

“The problem is we don’t have ambulance here”, said Masiso. “So I am using my car.”

“‘[For] those who are pregnant or sick. It’s lots!”, he emphasised. “Sometimes they call me at 12 in the evening and then I have to drive them.”

Masiso keeps track of the calls he responds to in a small book, and notes the reason for the emergency. Some of the reasons include “sick”, “stabbed”, “baby sick”, “mother”, or “GB” for giving birth. The majority of calls are noted “mother” or “sick”.

“Some deliver babies in the car”, said Masiso. He added that birthing complications were common in the community, and Dyantyi* agreed.

When Masiso is unavailable, the community suffers.

“Years ago I had a friend who was stabbed, and Sibongile was not available”, said Dyantyi*. “The wound was near his heart.”

Dyantyi* found someone to drive, and accompanied her friend to Canzibe. They arrived around midnight. “The condition of the person was really, really bad”, she said.

“There were no nurses, no doctors, the only person there was a community health worker.”

“It was just blood everywhere!”

Dyantyi* recalled that it took two hours for a doctor to arrive, but her friend’s condition had quickly deteriorated – he needed to go to Mthatha.

At 4am, Dyantyi’s* friend was taken by ambulance to Mthatha. “At that time he was already gasping, you could see that this person was going to die at any moment,” she said.

Despite a transfusion, Dyantyi’s* friend had lost too much blood and later passed away at Nelson Mandela Hospital.

“Most of the people in this community that pass away all die on the way to hospital”, said Dyantyi*.

“I want to stop using my car because the road is bad,” said Masiso. “But I am afraid people are going to die and then they will blame me.”

“That’s why I keep on taking them,” he said.

“Many communities in the Eastern Cape face the same problem,” said Thoko Mtsolongo, Eastern Cape Health Crisis Action Coalition co-ordinator. “In response to a report on emergency medical services produced by the South African Human Rights Commission in October 2015, the department said that it is had purchased 141 new vehicles.  However it has emerged that more than half of its 419 ambulances were reported in the depot unused because of minor faults during the last financial year. The department, by its own estimates, should have 667 ambulances but in effect there are only about 200 ambulances on the road servicing one of South Africa’s most vast provinces. It is extremely worrying because many have never seen ambulances in their villages and people die unnecessarily.”

It started in 2010

Masiso is part of the Mankosi Clinic Committee, and has been actively involved since 2010.

“People keep asking me when is the clinic going to open and I keep saying ‘I don’t know, I don’t know’.”

“Maybe someone can just come with a plan,” he said shaking his head. “I’ve been asking and asking, making phone calls, and I don’t know.”

“If the government can open Mankosi clinic I will be really happy.”, said Dyantyi*. “Some of the pregnant mothers lose their babies because of the long distance.”

Liyabona Ntsunguzi
Mankosi Community Member: “What I want to see happening with this clinic is for the government to open it officially; to have nurses working, to have medication and all the resources that are being used at a health facility. Also the fact that they could work during the night, this is what I would like to see happening at the clinic.”

Multiple sources told Spotlight that in 2010 there was a verbal and written agreement between the Mankosi community and the Eastern Cape Department of Health. The agreement was for the Department to run the clinic once it was built, however no proof of this agreement can be found.

In June 2016 the Department of Public Works inspected the clinic and held a meeting with the Mankosi community. Minutes from the inspection meeting state that the document detailing the results of the inspection was reportedly given to the Nyandeni sub-district clinic manager.

“[They] agreed that [they] received this but is not sure where it is on [their] desk,” state the minutes.

According to the register, the sub-district clinic manager was not in attendance at the meeting.

The meeting concluded with an agreement by Department of Health officials to submit a report on the clinic to Bhisho (the health department headquarters); inclusive of photos and comprehensive notes.

“The way forward is that [Department of Health official] will submit the report to Bhisho, [sub-district clinic manager] will submit the Public Works document again and the DoH will report back to the Mankosi Community within a week,” state the minutes.

More than two years later, the Mankosi Clinic remains empty; the community left in the dark, and the smell of fresh paint permeates the emptiness that has yet to see a patient.

Despite numerous attempts by Spotlight, the Department of Health failed to respond for comment on the matter.

Mankosi as a microcosm

In June of this year, Minister of Health Dr Aaron Motsoaledi assured the South African public that the health system was not collapsing. He argued that the country was still able to manage

HIV treatment for the majority of the population. Despite Motsoaledi’s sentiments, rural communities like Mankosi feel the neglect.

Data collected in 2017 stated that Mankosi had a 22 percent HIV infection rate, but with clinics and hospitals far from the community, residents battle to get life-saving medication.

Dyantyi* stated that in 2017 the Pilani Clinic was out of ARVs for almost three months. Spotlight later confirmed this information with a source.

“The clinic orders [medicines] but the clinic does not have a set date when the order will be delivered,” the source said. “That’s the biggest challenge.”

Masiso stated that on 22 October he visited Pilani for his young daughter but could not receive the appropriate medication.

“Sometimes Pilani just has Panado, no medicines,” said Masiso. “Allergex and Panado.”

Data shown to Spotlight from 2016 reveals that more than half (60%) of patient’s using Pilani Clinic were from Mankosi. This data stems from a headcount that took place at the clinic.

A source later provided a shocking list of Pilani clinic’s current stock-outs which included FDCs (fixed-dose combination ARVs), children’s antibiotics, betadine ointment and adult paracetamol.

The source added that the clinic also suffered from a severe shortage of staff. However, stock-outs and staff shortages in rural clinics and hospitals are nothing new.

Spotlight spoke to a staff member at Zithulele Hospital who explained how rural communities often felt the failures of the healthcare system the worst. Zithulele is perceived by Mankosi residents to be the best hospital in the area, but is almost two hours away by car. As a result, residents are often referred to Canzibe unless otherwise requested.

The staff member highlighted that the most common health concerns in the area were HIV, TB, child and maternal health issues; “the rural health big four”.

They emphasised the need to recruit “long-term staff” and to prioritise “team-building” at rural facilities. “There is no quick fix”, they said.

“We need to build momentum in the healthcare system”, the staff member said. “We need to be asking ourselves, how can we be making this better.”

Call to action

Rural Health Advocacy Project (RHAP) Health Systems and Policy Programme Manager Russell Rensburg said that the Eastern Cape had a problem with resource distribution. “One of the challenges is the proliferation of district hospitals and the underinvestment in primary healthcare,” said Rensburg.

“At the core you can’t solve the problem by looking at one aspect, you have to look at the Eastern Cape as a system.”

RHAP Project Coordinator, Mafoko Phomane, spoke about the disconnect within the province between sub-district and district management levels. Phomane outlined that the clinics were managed by the sub-district, while hospitals by the district.

“There’s a disconnect in terms of referral,” said Phomane. “Ultimately that is what causes dysfunction with primary healthcare and district services, and the Eastern Cape is worse because of the distances and roads.”

“To me the big story is the under investment in Pilani Clinic,” said Rensburg. “Because Pilani doesn’t have the equipment and staff to do the outreach they need.”

“If they were better capacitated and able to work in partnership with Mankosi it would solve the problem.”

“A quick-win would be the partnership between Pilani and Mankosi, how best can Pilani be resourced in order to support Mankosi,” said Phomane. “It’s not an impossible, whereas staffing Mankosi is almost impossible knowing the HRH and budget constraints.”

*Names have been changed to protect the identity of the source

**Pilani is alternatively spelled Philani

Kathryn Cleary is a health journalist with Grocott’s Mail in Makhanda, Eastern Cape and was commissioned by Spotlight to write this article.




OHSC – need we help it to do more?

The Rural Health Advocacy Project’s Samantha Khan-Gillmore makes a impassioned plea for the Office of Health Standards Compliance to be capacitated to do more.

In the early hours of the morning in January 2017, two young, energetic, men were involved in a serious collision and were immediately taken by ambulance to the nearest health facility for emergency treatment in Bizana, Eastern Cape. Between the two men, they had sustained head injuries, a broken jaw, shoulder, ribs and arm, a badly lacerated tongue, severe bruising and other cuts and abrasions. Eighteen hours after arrival at the facility they were yet to be seen by a health professional. No x-rays were done. No wounds were cleaned. No injuries were addressed. No medical care was given to either of them.

Shortly after the accident and upon arrival at the facility, a family member, Mr Mthethwa* was advised that the injured relatives would have to wait to be transferred to the nearest orthopaedic hospital in the Eastern Cape before they could receive much needed medical treatment.

Thirty-six (36) hours after the accident, the hospital staff informed the family that they could not be transferred to the next referral hospital until the following Wednesday – some five days after the accident. Mr Mthethwa took the decision to remove his family from the hospital’s care and personally transported them to a hospital in Durban where they finally received medical assistance.

Due to the delayed treatment, both young men do not have the full use of their arms, are undergoing intensive rehabilitative care and are no longer employable in their current positions which requires heavy lifting duties. One of the two young men is also now receiving a disability grant due to the injuries that do not allow him to secure full-time employment.

Persuant to the treatment of the young men at the hospital, Mr Mthethwa decided to approach the Office of Health Standards Compliance (OHSC) seeking recourse for what happened to his family. The introduction of the OHSC (through the National Health Amendment Act of 2013) is a great step towards health equity for patients and the health system as a whole because it is a regulator of quality healthcare for all. One of its core functions is to objectively assess the performance of health facilities towards the attainment of quality healthcare. In line with its mandate, the OHSC investigates complaints relating to breaches of prescribed norms and standards. The vision of the OHSC is “Safe and Quality Healthcare for all South Africans”

The hospital referred to in the complaint above is in the Alfred Nzo District of the Eastern Cape. Alfred Nzo District has a  population of 843 294 and a population density of 78.6 people per km2. The district comprises Maluti and uMzimvubu health sub-districts and falls within socio-economic Quintile 1, among the poorest districts in the country, according to the District Health Barometer 2016-2017. The health statistics are indicative of the Quintile 1 status. Less than 3% of households have piped water and less than 5% have flush toilets. Children under the age of five are prone to diarrhoea, which is often linked to poor sanitation and lack of clean water. Malnutrition in pre-school children is rife. With the publication of the District Health Barometer annually, Alfred Nzo consistently performs dismally with very poor health outcome indicators. Alfred Nzo has the lowest primary healthcare expenditure per capita for 2016/17 of all districts in the country at R617. The same district was also the lowest at R599 for 2015/16. It is evident that the Inverse Care Law is still very much alive – those most in need have the least available resources.

The main objectives of the OHSC are to protect and promote the health and safety of users. This may be a noble undertaking and despite the OHSC being a much needed intervention, it does not yet have the internal capacity to deal with the numerous challenges across the country. In the 2015/16 reporting period, the OHSC received 73 complaints. This has escalated to 1122 reports in the 2017/18 period. This increase could be due in part to the #LifeEsidimeni case but also because the OHSC is gaining traction and publicity through its National Core Standards which facilities must subscribe to. The volume and scope of complaints is vast and despite attempts to respond to each and every complaint received, this is clearly not possible. According to the OHSC Annual Report 2017/2018, most complaints originated from Gauteng (378) and KwaZulu-Natal (138). The Eastern Cape, the province with at least two of the most deprived districts in the country, lodged 129 complaints.

Mr Mthethwa remembers being at the hospital where his family did not receive treatment in the Eastern Cape. He heard a community member say that the hospital has a reputation in the community of being a place of death for sick people. Another community member says: “we call it the mortuary, because we do not come here for treatment – we come here to die.

In a meeting in August this year with the OHSC, while acknowledging the pain and distress of the family, the hospital cited staff shortages as the main reason for the lack of treatment on that fateful day. This may be true. Human resources for health are a scarcity in the current health system climate, particularly in the public sector and definitely in rural communities. The question is, are we prioritising the worst-off with our available resources and are we using human resources efficiently? The Clinical Associate profession was introduced into South African tertiary institutions in 2008 through a 3 year Bachelor of Clinical Medical Practice degree. The introduction of the new profession was a way of addressing the continuous and severe shortage of health care workers especially in the public health sector. Clinical associates are qualified to perform many clinical procedures including conducting consultations (history taking and physical examination); ordering and interpreting investigations (lab tests, X-rays) as well as to diagnose and treat common conditions.There are many unemployed clinical associates that are a cost-effective answer to improving access to clinicians particularly in rural and underserved areas. Why are we not utilising these available resources?

This hospital has unfortunately escaped the last three annual audits and inspections of the OHSC (only 700 facilities were inspected between 2016 and 2017) but it is clear that there are significant changes that need to occur for health users to be satisfied with the services received. While the OHSC has been instrumental in highlighting many health system challenges, do we not need to bring in the provincial departments of health to account for how it addresses the OHSC findings?

In dealing with hospitals such as the above, there are a few options available to provincial health departments to mitigate a better health passage for health users and to translate vision into action for deprived communities:

  • Prioritise the worst-off
  • Bend the rules and accredit facilities that far from meet the national core standards
  • Don’t accredit and leave rural communities out of sight and out of mind


Which one will it be? We trust that it will be the first option.

We want to see that facilities serving deprived communities are prioritised in the next phase of the NHI preparations. Soon enough, the excuse of low staff complement and lack of resources will no longer suffice for a population who is witness to daily healthcare challenges.

National and provincial treasury departments should ensure adequate funding provision for the OHSC in order for it to carry out its mandate efficiently and effectively. It is evident that greater powers should be afforded to the OHSC – without it, it remains a complaint tool with little or no executing powers As people living in South Africa, we need a body such as the OHSC, however we need one with not only a bark but a huge bite as well.

*Mthethwa is not his real name



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.