NDLOVU CARE GROUP (NCG) RURAL ADVANCEMENT PROGRAMME A RURAL MODEL FOR SOUTH AFRICA Impumelelo Platinum Award 2008 20%-40% of people in South Africa’s northern-most rural province of Limpopo 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 Elandsdoorn 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 Dennilton, 30kms from Groblersdal 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 Mpumalanga 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.