NDLOVU CARE GROUP (NCG) RURAL ADVANCEMENT PROGRAMME

A RURAL MODEL FOR

Impumelelo Platinum Award 2008

20%-40% of people in South Africa’s northern-most rural province of are HIV-positive and the delivery of basic services severely lacking. In response, one Dutch doctor and his wife, a nurse: Hugo and Liesje Tempelman started a clinic to get people in the community healthy so that they could deliver their own services. After more than 17 years of improving the health of people in this area, the Ndlovu Care Group has proved that HIV is not a death sentence but a capacity-builder.

Background

Dr Hugo Tempelman, a Dutch doctor, arrived in South Africa in 1990 and worked as a general practitioner in the former homeland of KwaNdebele in Limpopo. In 1994, he took out a bond on his house and built a rural clinic at , 30kms from on the R513 to Bronkhorstspruit in Limpopo. There was no medical infrastructure in the area which was nothing more than a large rural district comprising of scattered African settlements. Within a 10km radius, there are a number of townships with an estimated population of 120, 000 to 150,000 people. Due to this initiative’s success, Tempelman was described by Richard Branson in his latest book, Business Stripped Bare: Adventures of a Global Entrepreneur, as “a wonderful doctor and extraordinary social entrepreneur…Hugo had not only created a one-stop-shop for primary health-care to include a pharmacy, X-ray and obstetrics facilities, an HIV/AIDS-patient care clinic, and laboratory. He had helped create an entire economic infrastructure with basic utilities such as water, electricity, roads and even a bakery, a car wash and a nappy-manufacturing factory!” Medical Interventions

Since then, the clinic expanded exponentially as Hugo drew on the community to take charge of their own development. Ndlovu clinic now boasts a sophisticated medical centre that combines holistic HIV treatment, prevention and public health- care with community development, stimulation of entrepreneurship and self-help projects. The main focus is on HIV-awareness education and treatment, and one of its offshoots, the Autonomous Treatment Centre (ATC), runs a mobile clinic on farms to conduct HIV awareness education and testing (VCT).

Their Highly Active Anti-Retroviral Therapy (HAART) programme provides anti- retroviral treatment (ART) to roughly 2,500 patients in the area, and over 6,000 people are involved in voluntary counselling and testing (VCT). HIV patients are started on ARVs on a CD4 count of below 350, unlike government’s ART programme that starts on a CD4 count of only 200 when HIV patients enter the AIDS-defining period of weight loss, chronic diarrhoea, opportunistic infections and finally death.

Ndlovu Care Group was the first ARV provider in Limpopo, preceding government, with treatment regimes. One of the project’s innovations is its on-site laboratory, which specialises in HIV monitoring. This ATC laboratory, which conducts HIV tests, also performs CD4 examinations, assesses HIV patient’s viral loads as well as liver and kidney function. The laboratory has an integrated IT system, managed by members of the local community who received training from the Centre. It is a sophisticated data bank containing all the laboratory results and the patients’ electronic medical record. ATC runs a well-developed patient follow-up system and a programme measuring compliance, defaulting and viral suppression on-site. Its on- line system tracks those who receive ARTs, and alerts staff to defaulters.

The medical centre runs a Tuberculosis (TB) project, which provides TB diagnosis, treatment and care. A very important intervention to prevent patients developing resistance to ARVs is the monitoring programme. Defaulting patients are contacted and reminded to return to their medication. If this fails, a home visit is conducted. Defaulter tracing is combined with intensive and ongoing HIV counselling and education. The result is a defaulter and lost-to follow-up-rate of below 5%. The NCG does not only focus on HIV; it also runs the Columbine Maternity Clinic (CMC) which offers antenatal, obstetrics and postnatal services. It is staffed by three midwives, four enrolled nurses, four auxiliary nurses, and provides a weekly family planning clinic. The CMC focuses on prevention of mother-to-child-transmission (PMTCT); pregnant mothers are encouraged to undergo HIV tests; HAART is then initiated during pregnancy to achieve an undetectable viral load at birth (reducing the chances of HIV transmission during delivery); and the neonate is treated for four weeks after delivery. To prevent HIV transmission through breastfeeding, the women receive formula milk to feed their babies. Since 2003, the mother-to-child- transmission rate declined dramatically to 0%.

Another ground-breaking initiative is a day clinic at the Dennilton medical centre, which is staffed by a clinic manager, five medical doctors, nursing staff, a microbiologist, radiologists, medical technicians and a pharmacist. The medical centre employs a total of ninety local people from the area as home-based care- givers and HIV counsellors. It has three consulting rooms, a theatre for minor surgery, a pharmacy and a computerised X-ray facility that captures digital images for consultations. In addition, a HIV in-patient care facility attached to the clinic and a nappy factory, an administration annex and accommodation quarters for the nurses, complete the precinct. Finally, the ATC runs a Community Dental Clinic, which has a truck equipped as a dental unit, servicing all the local schools. Roughly 2,300 children are screened by this unit each year.

In 2007, a second medical centre, Bhubezi, was opened in the Bushbuckridge district, near the Kruger Park boundary in the Lowveld in the province. It was funded by Virgin Unite, Anglo Coal and the US President’s Emergency Programme for AIDS Relief (PEPFAR). As Branson suggests, it is “a brilliant example of the kind of public and private partnerships that really work, where health officials and the business community are working hand in glove to fight AIDS more effectively”. Bhubezi has shown amazing progress since opening and at the time of Impumelelo’s visit in October 2009. It already provided ARVs to 2,541 HIV patients. It mirrors the Dennilton medical centre except that it has no maternity clinic per se. Bhubezi is staffed by three general practitioners, with rural origins in Mpumalanga, trained at the University of Cape Town and Medunsa. The doctor in charge, for example, grew up in a local village about 10 kms from the clinic. A third medical centre, Nyanti that was opened near Acornhoek in the Lowveld also replicates the ATC model. This clinic is sponsored by a South African financier who owns a game lodge in the area.

As pointed out, the Ndlovu Medical Trust won an Impumelelo Platinum Award in 2008 for its exceptional HIV/AIDS and health-care programme and the 2010 Social Entrepreneur Award for its broad socio-economic and health impact on the region. More importantly, it uses the health-care centre as the fulcrum around which all its other rural development initiatives revolve. Over the past 17 years, it has grown into a holistic integrated rural development programme that has incubated several small and medium enterprises creating an entire socio-economic infrastructure promoting the broader development of the area.

Development Intervention

Job creation

Ndlovu Medical Trust (NMT) has its own construction company, called ‘Friends in Community Development’. It employs a full-time staff of 18 construction workers and 8 local people working in the maintenance workshop. Over the years, they constructed the medical infrastructure and other buildings for the NMT. These include the Medical Centre, the Johan Cruyff Sports Complex, an amphitheatre, water and sewerage infrastructure, and a number of pre-schools.

A grade 10 pupil, Mafikia approached Hugo Tempelman a few years ago for a job and asked whether he could wash the Centre’s fleet of vehicles. He washed 20 cars every weekend and earned R 400. He later started washing Eskom’s vehicles as well. Soon he managed a car wash business and employed three of his friends. A Dutch donor who owns Bling Car Wash franchise in Appeldoorn in the Netherlands visited Ndlovu. He wanted to support a project and donated money to Mafikia’s car wash business. Mafika set up a shaded parking area, bought vacuum cleaners and installed electricity, and other necessities. Today, it is a thriving small business and employs 4-5 local young men on a full-time basis. Three young entrepreneurs registered “a painting business as a closed corporation”, Three Coat Paint CC. Unfortunately they had no clients or start-up capital. NMT gave them work and retained a percentage of the fees to assist them in building a saving fund. When they needed a compressor and other equipment to tender for a large painting job in Groblersdal, NMT provided a loan of R50, 000 to enable them not only to purchase the equipment but also to tender successfully for this job. The loan was repaid within two months, and they subsequently borrowed another R65, 000 to buy an Isuzu bakkie. The organisation has developed into a successful business, which employs a number of local members of the community, pays income tax and contributes to the unemployment insurance fund for employees. As such it is a good example of the type of Small-Medium Enterprises which have been incubated as an economic development spin-off around the Ndlovu Medical Centre.

An example of a SME that was established through the entry point of health-care is the nappy-manufacturing that was started on the Centre’s premises. It is run by two HIV-positive women who gave birth to HIV–babies at the Columbine Maternity Clinic, and who were subsequently abandoned by their fathers. Hugo assisted the women to establish the Nappy factory and bought machinery sponsored by Dutch donors. It sells nappies to spaza shops in the area and at other outlets; it also supplies nappies to the maternity clinic and adult nappies to the medical centre.

Other entrepreneurial efforts incubated in the local community include a small eatery and take-away next to the medical centre, a bakery, an information technology school and an internet café. The eatery was conceptualized by Ndlovu as an alternative to a staff canteen at the medical centre. Hugo Tempelman assisted a family business with refurbishing a small eating place, bought cutlery and chairs and tables and provided the family with a small loan to buy stock. Similarly, it assisted in the establishment of a bakery back in 1998 which at present employs a staff of 12 local people and bakes bread for all the ‘spaza’ shops in the area.

As highlighted in the previous section, NMT also trained many young people in information technology (IT) specifically as data capturers at its IT monitoring and evaluation unit. Fortunate school leavers gain extensive experience in IT work and subsequently moved into the formal economy and found jobs in the city. The creation of an IT school and internet café with affordable access to Facebook, Google and Play Station computer games has become an indispensable resource to schoolchildren who often are denied these resources in rural areas.

Child-centred development

Ndlovu extensively supports community development initiatives focusing on children. They run four nutritional units, located at pre-schools in the area to address the underlying cause of malnutrition, diarrhoea or pneumonia. At each nutritional unit, water infrastructure was installed and a vegetable garden was set up. Around 250 children are enrolled each year and they are fed at these units until they are back on a normal growth path. The mothers or care-givers are taught by locally-trained community health workers (CHWs) how to start a home garden and how to improve the home situation with regard to nutrition, sanitation and hygiene, healthy food and caring for children. The care-givers are provided with seedlings and a garden tool set in order to start their own vegetable gardens. The aim is to improve the nutritional status of the household with minimal financial inputs, using the available human resources of the household instead. The CHWs carry out regular home visits to monitor the children and the progress of the home garden.

At the nutritional units, the centre runs four pre-schools that care for around 400 children each year. At each school, feeding schemes are run to complement their education. Although these pre-schools were initiated and built by NCG, they have now been handed over to the Mpumalanga Department of Education. This cluster of interventions is functioning through donations from the Nelson Mandela Children Fund and the Vodacom Foundation.

An enormous amount of children are growing up without parental or family guidance as a result of the pandemic. NCG runs an Orphan and Vulnerable Children (OVC) Programme which focuses on building the capacity of community-based organizations, child protection structures, home-based-carers and OVC guardians. Ndlovu works closely with the Department of Social Services and assists this vulnerable group of AIDS orphans in obtaining their social grants. Since January 2007, some 3,100 children have been registered. In the nearby Loskop Dam Nature Reserve, Ndlovu set up a tented camp for the children to educate them about nature conservation and respect for the environment. Social Infrastructure Development

Ndlovu has also constructed a large amphitheatre that is used for events such as Heritage Day, World AIDS Day and so on. A multi-purpose community centre behind the amphitheatre projects films onto a big screen in the evenings once or twice a week to provide entertainment to a community denied this form of leisure. The projects’ showpiece, however, is the Ndlovu 60 member youth choir.

The choir master of the Ndlovu youth choir is Ralph Schmidt, a top musician, who previously conducted the Johannesburg youth choir and earlier the Drakensberg boys choir. Recently the choir has performed at the Tshwane Arts Festival in Pretoria during the closing ceremony at Pretoria University and has been invited to sing at the forthcoming Table Grape Industry Fair in London. A local conductor from the area is undergoing training at the Royal Music Academy in London and 60 children are receiving long distance learning in music theory through the Royal Academy.

Ndlovu has built a sports complex with a Cruyff court (e.g. a technical soccer field 1/8 the size of a normal soccer field) and a netball, basketball, tennis and volley ball courts as well as a gymnasium. It was a Friends in Community Development construction project and 80 local people built the complex, project-managed by a Dutch volunteer. The complex is run as a self-sufficient enterprise. The well- equipped gymnasium with all the necessary cardio exercise machines, weights and hot water shower facilities is a paid service with membership fees at R80 a month, which covers the salaries of six instructors. They coach the youth in the various sports disciplines. The sports complex was sponsored by the Johan Cruyff Foundation, a Dutch soccer star and manager of Barcelona FC. At the opening, on 7 November 2005, he played in a soccer team together with 11 HIV-positive players in jerseys with the slogan: ‘We will all be here in 2010’.

In 2007, a soccer development project was undertaken by the Royal Dutch Football Association. It sent trainers from the Netherlands, Kenya and Zambia to provide training to coaches in the area. As a result there exists a well-run soccer league in the area and the local coaches were trained for two months by the Zambian national coach, Mr. Kalusha, and two other coaches from Kenya. The tennis club has brought out Paul Haarhuis and Jaco Eltingh, the Dutch world champion doubles pair, for the last two years in order to coach promising young local tennis players. Finally, a long- distance running club also operates from the sports complex and members of the club have obtained bursaries for tertiary education.

Development and support of basic services

The existing water infrastructure and reticulation system in rural area is wholly inadequate for the community and the water supply to homes and schools is irregular. The Department of Water Affairs and Forestry (DWAF) plans to construct a pipeline from Loskop Dam about 30 km to the east with a reservoir, purification plant and enhanced reticulation to supply this region. Unfortunately this will take another five to ten years to materialize. In the interim, the NMT provides basic water infrastructure e.g. 36 boreholes with electrical pumps, water tank towers and standpipes in local communities. It further improved the water situation by establishing a maintenance team that repairs and services the water pumps and fixes the leaks. Water Boards were set up in the communities to manage their own water resources locally. At present the NMT is putting in six more of these water supply systems and have funds for another twelve.

It is well-recognized that waste management is poorly organised in rural areas as shown by the baseline survey on service delivery conducted by the Department of Social Development in 13 Presidential rural nodes in 2006. 77% of the rural households in the survey labelled refuse removal as of a ‘poor quality’. To address the total absence of a municipal refuse removal service in Dennilton, the NCG built collection points where people could deposit sold waste (pictured above). It set up a business that employs seven local people who collect the garbage by a truck and transport it to a landfill. It designed a medical waste incinerator to confiscate dangerous medical waste in such a way as to leave no trace of it anywhere. This invention is indeed an innovation that should be replicated all over the developing world!

For a video on this program, please visit http://www.youtube.com/watch?v=4G-2GWvlN1g