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Empowering health: the vital role of nomakhayas in South Africa's path to universal coverage

Empowering health: the vital role of nomakhayas in South Africa's path to universal coverage
BY THE BOOK: Asonwabisa Sipatana’s primary healthcare training includes how to monitor high blood pressure and help those with diabetes and HIV, as well as provide maternal and child health support. (Photo: Bulungula Incubator)
Sigrid Kite-Banks
By Sigrid Kite-Banks
30 Jan 2025
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Community health workers — also known as ooNomakhaya in isiXhosa — fill a major gap in healthcare in hard-to-reach places. Which is why National Health Insurance (NHI) needs to make sure they are part of the plan.

In the deep rural Eastern Cape, where clinics are far away and the roads are treacherous, healthcare comes not in standard medical facilities but through the quiet resilience of community health workers, or ooNomakhaya (isiXhosa for “home carers”), as they are affectionately called. 

One such nomakhaya is 30-year-old Asonwabisa Sipatana, whose work intertwines with her family’s legacy of healing.

Sipatana’s grandmother, Nozolile Zintoyinto, is a respected sangoma in the village of Nqileni in the Eastern Cape. At 93, she has spent more than six decades as a spiritual and physical healer. Today, Zintoyinto watches her granddaughter carry this legacy forward in her role as a nomakhaya.

“I am deeply proud of Asonwabisa,” she says. “Healing is not just a job. It is a calling passed down from our ancestors. Though she wears a different uniform, her work brings comfort to those who suffer and peace to their hearts.”

Sipatana is a lifeline for her community. Her work goes beyond her training in primary healthcare — it is deeply rooted in an understanding of her community’s values, practices and unique challenges. 

Sipatana helps care for her grandmother, Nozolile Zintoyinto, a respected village sangoma. (Photo: Bulungula Incubator)



Like the 19 other Nomakhayas employed by the Bulungula Incubator, the nonprofit where I work, she plays an essential role in delivering healthcare at home. Nomakhayas conduct health screenings for conditions such as high blood pressure, diabetes and HIV. They also provide maternal and child health support, monitor early childhood development, assist people with disabilities, and make sure the community is aware of health emergencies such as disease outbreaks. 

The blend of proximity, professional knowledge and cultural insight make nomakhayas indispensable to the planned National Health Insurance (NHI) scheme, particularly in hard-to-reach areas where trust and familiarity are just as vital as medicine.

Barriers to healthcare in rural areas


For many in rural South Africa, accessing healthcare is fraught with challenges. Clinics are often located hours away, requiring expensive or exhausting trips that many cannot afford. And even when patients do reach a clinic, they can be met with overburdened staff, long queues and a rushed, impersonal experience.

This dynamic is particularly complex in poor communities. Decades of systemic inequities mean many people are reluctant to question or approach healthcare providers in positions of authority.

This can lead to delayed care, a patchy health history and poor adherence to treatment plans — factors that can severely affect health.

The nomakhaya difference


Nomakhayas are not outsiders; they are members of the communities they serve. As neighbours, friends and relatives, they share the same language, culture and daily struggles as the people they care for. This shared experience creates a level of trust and familiarity that conventional healthcare systems often struggle to achieve.

Nomakhayas also visit patients in their homes. This approach mirrors the practices of traditional healing that have been part of rural communities for generations. Like sangomas, nomakhayas are able to take the time to understand the symptoms of an illness as well as the broader context of a patient’s life, including their family dynamic and emotional and social wellbeing.

“I don’t just see their illness,” Sipatana explains. “I see their story. I know if they’re struggling to buy food, if their children are living with them or if they’re unable to collect their medication from the clinic because they can’t afford the taxi fare. These things matter because they affect how someone gets better.”

This connection makes nomakhayas highly effective at managing chronic conditions, ensuring children are on track with immunisations and promoting preventive health practices. Over the past 14 years that Bulungula’s community health worker programme has been operating, we have found that patients are more likely to tell their nomakhaya about sensitive health information and follow their medical advice because they feel understood and respected.

When trust makes the difference


This approach is the reason a one-year-old child in the community is alive and healthy today. During routine home visits, a nomakhaya noticed that the child was persistently underweight and sickly. She contacted the child’s mother, who was working outside the community, and discovered that the child was HIV-positive. But she had not been receiving treatment. The mother had not disclosed her status to the grandmother caring for the child and wanted to keep it confidential.

Asonwabisa Sipatana’s primary healthcare training includes how to monitor high blood pressure and help those with diabetes and HIV, as well as provide maternal and child health support. (Photo: Bulungula Incubator)



Because of the nomakhaya’s trusted relationship with the mother and family, she could intervene quickly. She linked the child to a hospital and told the medical team about the need for confidentiality. The child was immediately started on lifesaving HIV medication. The hospital then worked with the nomakhaya, who continued to visit the home twice daily to give the child medication, ensuring the child’s recovery while honouring the mother’s wishes for privacy of her HIV status.

Today, the child is healthy. Without the nomakhaya’s intervention, the child probably would not have survived.

Toward universal health coverage


As South Africa moves toward rolling out the NHI, the success of nomakhayas offers a powerful lesson. We need more than infrastructure and resources; we need a healthcare system that meets the specific needs of South Africa’s diverse communities.

The effectiveness of nomakhayas lies not just in what they do, but in how they do it. In rural areas, where access to clinics is limited, about 70% of South Africans turn to sangomas for care before consulting a medical doctor. Nomakhayas are from the community and based in the community, so their approach naturally reflects the community's existing healthcare practices. 

“Nomakhayas are not confined to only one way of healing,” Zintoyinto says. “They understand the ways of our ancestors and the knowledge of modern medicine. They carry both types of wisdom to bridge the old ways and what is useful in the new. This balance is important. Sometimes, our traditional remedies ease pain or bring comfort, while modern treatments address the cause. Together, they can serve our people fully.”

Here’s how we can improve South Africa’s healthcare system to prepare it for the NHI, or another form of healthcare for all:

  1. Recognise the unique value of community health workers. They are not just “task shifting” — taking on the time-consuming jobs of other medical professionals — but creating trust and strong relationships with their patients that can improve health outcomes while easing the strain on clinics/hospitals and reducing the need for costly care.

  2. Invest in their future. Building a standardised community health worker system that works across all provinces should include proper training, fair pay and job security.

  3. Learn from their approach. Incorporating cultural understanding into healthcare delivery would make health coverage truly universal.


Instead of creating entirely new systems, health services can follow models that are already working in rural communities. Nomakhayas bridge the gap between traditional and modern healthcare, that makes sense — and makes an impact. DM 

Sigrid Kite-Banks is the strategic communications manager at Bulungula Incubator. The NGO has a team of 20 nomakhayas who serve the Xhora Mouth Administrative Area in the Eastern Cape.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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