National Health Insurance lessons for deep rural South Africa

The small, rickety ferry used to terrify Bongezwa Sontundu, 35. She can’t swim, but she had to cross the breadth of the Xhora River Mouth in the rural Eastern Cape to get to a clinic or hospital. 

On the other side, she faced a two-hour walk to the facility, then another two to three hours of queueing before she got help.

One such trip, which Sontundu made while she was pregnant, was nearly deadly for her unborn child.

The heat of the trek had been too much for her body to handle.

Bulungula Health Point waiting area, child immunisation day, Nqeleni Village, Eastern Cape. (Photo: Sigrid Kite)

By the time she got to the hospital, Sontundu and her unborn baby were both seriously unwell and she had to be admitted for an emergency caesarean section.

Her child survived, but it wasn’t the last time Sontundu had to walk the long and winding path for healthcare.

She’s a mother of four, so altogether, Sontundu has spent more than 200 hours walking to and from the clinic to keep her children on track with the 16 immunisations, 10 doses of Vitamin A and nine courses of deworming pills the government says they need to receive before the age of 12.

But all that changed in 2021. 

These days, the farthest Sontundu has to commute with her youngest, a newborn, is a five-minute walk.

Introducing the Bulungula Incubator’s Health Point — open six days a week

The Bulungula Incubator’s (BI) Health Point is a simple, two-room structure that stands among the homesteads of Nqileni village, about 60km southeast of Elliotdale. The BI is a nonprofit that has been working in Nqileni and three surrounding villages since 2004.

Immunisations from DoH that the Bulungula Health Point keeps in solar refrigerator, Nqileni Village, Eastern Cape. (Photo: Sigrid Kite)

The community donated the building materials and the land on which the Health Point is built.

Open six days a week, the Health Point is staffed by two nurses. One nurse’s salary is paid by the health department and the other by the BI.

The BI and the provincial government opened the facility a decade ago after Xhora Mouth Administrative Area community members explained to them how hard it was to get to faraway state facilities to collect their HIV treatment or to get tested for the virus.

The Xhora Mouth Administrative Area is made up of four villages, of which Nqileni is one.

Here, being far from healthcare is the biggest reason why children don’t get fully vaccinated against childhood diseases,  a 2011 BI survey shows.

It’s also why half of mothers in the area have lost at least one child to diarrhoeal diseases, and why, until the Health Point was built, many people with HIV couldn’t access their medication regularly enough to adhere to it or high blood pressure went untreated, leading to many preventable strokes or heart attacks.

Bulungula Health Point, Nqilene Village, Eastern Cape. (Photo: Sigrid Kite)

The distances people would have to travel to get to clinics and hospitals is also one of the biggest challenges facing the country’s planned National Health Insurance (NHI) scheme.

The NHI aims to give all South Africans free access to at least basic health services, so that how much someone can pay for healthcare doesn’t determine how much care they can get.

Building enough fully-fledged clinics and hospitals in rural areas, so that people can access healthcare relatively close to their homes, will take time — and money. But cheaper and smaller facilities such as health points could help if they’re also equipped with well-run community health worker teams. 

But how do you set up these facilities and how should community health worker teams be managed? 

At the Bulungula Incubator we’ve learned three lessons, which we’ve come to think about as the three legs of a cast iron potjie.  

Lesson 1: Build trust and relationships: you’ll get nowhere without these 

Which services does the Health Point provide? 

People can come and pick up their chronic medications (such as drugs for HIV, hypertension and diabetes), and the nurses can treat minor injuries, as well as colds and pains.

Bulungula Health Point cold chain system, Eastern Cape. (Photo: Sigrid Kite)

And since last year, a solar-powered fridge is used to store vaccines.  

When it was first set up in 2012, the Bulungula Health Point was an ideal site for mobile health clinics to park their units, and for support groups and health outreach teams to host their events to teach the community about the risks of HIV, TB, high blood pressure and alcohol abuse. 

HIV support groups were accommodated at the Health Point, and people knew it was a reliable place to get their HIV treatment.

The facility has now become a government-accredited primary healthcare provider. It outgrew its original mud-brick hut and the community has built a two-room structure with a waiting area to cater for its expansion.

The facility sees more than 500 patients a month — most cases are treated on-site, with only about 7% referred to a clinic or hospital for more specialised treatment, BI data shows. 

But none of this would have happened without two things: The community’s buy-in and the Eastern Cape health department’s resources. 

The community’s buy-in provided us with buildings to house the Health Point; and health department resources supplied us with medicine and medical material such as bandages, gloves and needles to use at the facility.

Covid-19 vaccination outreach day hosted by the Bulungula Incubator with the Department of Health, Mgonjweni Great Place (home of chief No-Ofisi), Eastern Cape. (Photo: Sigrid Kite)

How did we build these relationships? 

With a considerable amount of patience — and time. 

The BI’s relationship with the provincial health department, for one, began a decade ago, when the department helped us to provide HIV treatment at outreach events, or by sending specialist doctors (such as dentists) to the Health Point. 

By the time the Covid pandemic hit, our relationship with the government had grown to such an extent that the department asked the BI to lead vaccination campaigns in the area. 

We’ve been able to demonstrate that our approach to improving health in our community works. 

The BI fills the gap that the government can’t, and it’s paid off: The Eastern Cape health department now funds roughly three-quarters of the costs of our health programme. 

But getting funding from the government would have been useless if the community didn’t trust us to deliver health services. 

The success of this relationship also lies in consistency. The BI didn’t just promise services to our community; we delivered, and have been doing so for more than 10 years.

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It also lies in connectedness: The fact that the BI office and 100% of our employees are based in the community we serve, means we can respond to people’s needs quickly.

And there is no difference between the healthcare that BI staff can access and what our community gets. So the lack of access to healthcare affects all of us equally and that accountability builds trust.

Lesson 2:  Nonprofits can’t operate alone — especially in rural areas

Now that community members can get to a health centre more easily, they are being diagnosed with conditions such as high blood pressure in time to be treated early. 

This is easing the workload of the doctors at government hospitals in the region, says Songezo Conjwa, the sub-district manager for the Mbhashe municipality. Early interventions at the community level decrease the number of people who need expensive hospital care, he says. 

But because BI’s Health Point is remote, there’s a limit to the services it can provide.

The facility is, for example, not on a laboratory route, so it isn’t feasible to collect blood samples for tests that show how much HIV there is in someone’s blood (such tests show health workers if someone’s HIV treatment works well) because the samples won’t be collected by the health department to be taken to a lab.

Nomakhaya doing growth monitoring at Jujurha Preschool, Nqileni Village, Eastern Cape. (Photo: Sigrid Kite)

To get around this problem, the BI’s health programme manager and the nurse at the Health Point work closely with Nkanya Clinic, the nearest government facility that is on a laboratory route. So when someone at the Health Point needs a blood test, their blood sample will be dropped off at Nkanya Clinic by the BI’s driver.

But that means that such samples are only taken at the Health Point once a week on Wednesdays, to make sure that the samples get to the state facility in time to be collected by the health department. A car, paid for by the BI, drives the two-and-a-half hours it takes to get to Nkanya Clinic from the Health Point, and that’s just one way.

Under the NHI, only facilities that pass an inspection by the Office of Health Standards Compliance will be contracted by the scheme to provide services.  

This will apply to both public and private sector facilities. 

In a bid to get facilities up to the required standard, the health department rolled out the Ideal Clinic framework in 2013. 

This is a list of checks and balances that sets the standard for what a clinic or hospital’s infrastructure should look like, as well as the medicine supplies, admin processes and staff complement in order to provide quality healthcare.

Nomakhaya doing growth monitoring at Juhurha Preschool, Nqileni Village, Eastern Cape. (Photo: Sigrid Kite)

The BI will soon start to use these same guidelines at the Health Point. We see this as a crucial step to ensure the Xhora Mouth Administrative Area community keeps getting key health services once the NHI rolls around.  

But we won’t be able to operate as well as we do without our partnerships with the staff at Nkanya Clinic, Jalamba Clinic, Zithulele Hospital or Madwaleni Hospital.

Lesson 3: Employ community health workers permanently, they’re worth it

The Bulungula Health Point would be far less effective if it didn’t have a dedicated team of 20 community health workers to help, says Yamkela Sapepa, one of the nurses at the facility.

These workers (whom the BI has dubbed nomakhayas) go door-to-door to every household in our community. Nomakhaya is an isiXhosa term for “home carer”. They visit about 450 households each month, teaching people about the importance of getting a Covid vaccine, testing people’s blood pressure and blood sugar levels and keeping an eye on how fast or slow babies are growing.

The nomakhayas also help people apply for child support grants and assist community members to test for HIV with home tests. They even help people with disabilities to do exercises to ease muscle pain or to recover from injuries.

If they pick up anything that’s awry, nomakhayas ask people to go to the Health Point.

Nurse Sapepa at the Health Point works closely with the nomakhayas. If a patient is, for instance, given blood pressure medication at the facility, Sapepa can count on the community health workers to make sure that person is taking their medicine correctly.

Nomakhaya taking blood pressure during a home visit, Nqileni Village, Eastern Cape. (Photo: Sigrid Kite)

The BI and its health programme manager will brainstorm solutions if the nomakhayas report that they struggle to get the patient to do so. 

“This two-way aspect that the nomakhayas bring to the health system is what truly improves the community’s quality of life,” says Réjane Woodroffe, the Bulungula Incubator’s co-founder and director. “That, and their trustworthiness, makes these health workers’ value immeasurable, because it literally saves lives.”  

During a routine visit earlier this year one of the BI’s nomakhayas noticed that a young child of about 18 months was underweight and sickly.

While the child’s mother was away from the village for work, the little one was in her grandmother’s care. The elderly lady didn’t know what was wrong, but the nomakhaya solved the mystery with just one call. 

The child’s mother told the nomakhaya over the phone that her daughter was HIV positive, but that she didn’t want anyone to know. That meant that the little girl wasn’t getting her antiretroviral medication, because her grandmother didn’t know she had HIV.

As a result of the nomakhaya’s intervention, the baby was immediately referred to the hospital where she got emergency treatment for a week. She survived, and when she was discharged, the hospital asked the nomakhaya to visit the home twice a day to give the child her HIV treatment. 

If the mother hadn’t trusted the nomakhaya to keep her child’s HIV status confidential, it’s likely that the baby would’ve died. 

And, if the hospital hadn’t trusted the nomakhaya to make sure the child is kept on HIV treatment, her health may have deteriorated again. 

One of the main reasons why the BI’s nomakhaya programme is successful is because our workers are employed full-time. 

Community health workers who work for the state, on the other hand, aren’t employed permanently. They sign temporary, often one-year contracts with provincial departments and work for a meagre stipend. Or, they’re employed by nonprofits who work with provincial health departments to deploy the workers. These conditions leave community health workers without much job security or the benefits that come with other government jobs. 

During the Covid pandemic, community health workers played an invaluable role by going from door to door to inform people about the virus, helping with contact tracing or registering people to get vaccinated. 

Still, it seems it could be years before these workers are made a permanent part of the health system. The health department said in July that all community health workers would get a stipend of just over R4,000 per month until 2025, and that their pay would increase each year while negotiations to make them official health staff are under way.

The Covid-19 pandemic really tested the health services in the Xhora Mouth Administrative Area, but even in times of uncertainty, Bulungula Incubator’s three-legged potjie hasn’t wobbled.

The community saw relatively few Covid deaths, and its vaccination rates are among the highest in the country, all thanks to the health system in place.

Bongezwa Sontundu is a full-time BI employee and the main breadwinner of her household.

She says the energy and time she saves because she no longer has to take the strenuous trip between the government clinic and her home dramatically reduces her everyday stress.

The health of the community would be far poorer without the Health Point and the nomakhayas, Sontundu concludes: “It would be a disaster.” DM/MC

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

Sigrid Kite is the content manager at the Bulungula Incubator.