United Nations Public Service Awards Case Studies

South Africa faces one of the most serious HIV epidemics in the world. More than 5 million South Africans were estimated to be living with HIV in 2008; with a national adult prevalence of roughly 10.9%. The figures vary dramatically between different provinces of the country, with the more rural areas being more heavily affected. The Western Cape (relatively urban and developed) has a prevalence estimated at roughly 3.8%, while more rural areas of the country have much higher estimates. Eg. KwaZulu-Natal at 15.8%, and Mpumalanga at 15.4%. Government response to this crisis has, until recently, been completely inadequate and counter-productive. An article in the Journal of AIDS estimated that the HIV policies by the previous government directly led to roughly 330 000 deaths between 2000 and 2005; and 35 000 babies were born HIV+ in this time. More recently, anti-retroviral treatment (ART) has become freely available at clinics, but many people (especially those in more rural areas) do not have access to the clinics to be able to receive these medications; or they are unable to visit the clinics regularly, and so default on their treatment schedules. Many are also unable to afford to access the clinics, due to high unemployment and poverty in rural areas. (All statistics are from the HSRC Third National HIV Prevalence Survey 2008).

Women face a much higher burden of the HIV epidemic – in almost all age categories, women’s prevalence rates are much higher than for males. In the 20-24 age group, women have a prevalence of 21.1%, compared to only 5.1% for males; and 25-29 group, women’s prevalence is at 32.7%, with men at 15.7%. This is especially worrying as these are the major child-bearing ages for women, meaning that many children are also placed at risk. An estimated 60 000 – 70 000 children are infected each year, and it is estimated that, without any interventions, the chances of mother-to-child transmission are 25-45%. However, with Highly Active ART (HAART), the transmission rate can drop to almost 0%. Once again, although this treatment is freely available at clinics, many women are unable to access these clinics (statistics from Health Systems Trust Prevention of Mother to Child Transmission 2009). Farm workers are also severely affected by HIV, as they often live in remote areas with little access to treatment, and no money to attend available clinics.

HIV also increases the incidence of other communicable and opportunistic diseases, such as tuberculosis (TB), malaria, and sexually transmitted infections (STIs). In the past 15 years, incidences of TB almost tripled in countries with high HIV prevalence (www.stoptb.org). Co-infection rates in South Africa are also very high, with an HIV prevalence of almost 75% amongst those with TB (Statistics South Africa – Mortality and causes of death in South Africa, 2006). Poor nutrition and hygiene also contribute to increased levels of communicable infections; and decrease the effectiveness of any treatments being undertaken by patients. Thus, the burden facing the healthcare system across South Africa is immense, but it even more severe in rural areas.

What is the initiative about? (the solution)
The original Ndlovu Medical Centre was established in 1994 by Dr Hugo Tempelman and his wife Liesje. The programme has since developed into the Rural Advancement Programme (RAP), which aims to provide services to the community, but which also empowers them to start taking over the provision of these services themselves. The RAP approach consists of two branches – Autonomous Treatment Centres (ATC) and Community Care, Health, Awareness and Mobilisation Programmes (CHAMP). The aim is to establish five RAP centres across the country. Thus far, Ndlovu Care Group has both an ATC and CHAMP; Bhubezi has an ATC and CHAMP in progress; and Waterberg has a satellite ATC (initiated by another NGO). The Ndlovu Care Group has 350 staff, more than 90% of whom are local community members. A more recent project has been the development of a small-scale incinerator where all medical waste can be disposed of safely, and in an environmentally-friendly manner. ATCs have three main branches: a 12-hour Community Health Clinic; a 24-hour maternity and in-patient care unit; and a decentralised laboratory, x-ray, pharmacy, and monitoring and evaluation services. The 12-hour clinic provides primary health care; highly active anti-retroviral treatment (HAART – incorporating voluntary counselling and testing to 6000 people per year; counselling; ART to 2500 people by 2007; and a mobile farm clinic); and a TB programme which enrolled 1500 patients in 2006 (including TB diagnosis, treatment and adherence management). The 24-hour clinic provides ante-natal care and prevention of mother-to-child transmission (PMTCT – the rate has been at 0% MTCT since 2003); maternity care (providing services for delivery and post-natal care); and an in-patient programme for TB and HIV patients. The incinerator means that all medical waste is able to be disposed of on-site, without being transported to another facility. It has a capacity of 8-10kgs at a time, and this is reduced to 150g; while the ash was leach-tested, and showed no contamination of soil or ground water took place. It therefore ensures that the waste is incinerated in an environmentally-friendly manner. CHAMP aims to create awareness and provide education to the communities. This includes a children’s programme; a sports, art and culture programme; and community development. The children’s programme includes four nutritional units (which provide nutritional information to heads of households, along with advice on how to develop a food garden, enrolling 250 households a year) and four pre-schools (which provide schooling for vulnerable children, including a feeding scheme); an orphans and vulnerable children (OVC) programme which has 3100 children enrolled and 58 registered households (assisting orphans to access social care grants, establishing community-based child protection structures, and training home-based carers); a mobile dental programme (which scans around 2300 children per year); and an educational environmental programme. The sports, arts and culture programme includes soccer, netball, basketball, a gymnasium, running, a choir, a music academy, sports grounds, and a life skills programme. Community Development involves developing entrepreneurship (helping to establish SMMEs); a nappy factory, car wash and bakery; a water project (drilling bore holes and handing 30 over to the community since 1998); and a refuse removal project. A full-time community liaison works between the community and the centre to ensure good working relationships.

Who proposed the solution, who implemented it and who were the stakeholders?
The original Ndlovu Medical Centre was established Dr Hugo Tempelman and his wife Leisje in 1994. After some time, it became apparent that simply providing medical care would not be sufficient, and they decided to change the focus to prevention, awareness-raising and education, to help address the root causes of the medical problems in the community. Involving the community and empowering them to take over the running of the project in the future was an important factor; as was designing a model that could be replicated in other areas. The initial design of the ATCs and CHAMP was established through consultation between the Tempelmans and local medical professionals working at the Medical Centre. Local community members were hired to work in both the ATCs and CHAMP to encourage capacity-building in the area. The incinerator was developed by Hugo Tempelman and a kiln and furnace specialist from Ultrafurn. Both contributed to its design, implementation and funding. The RAP programme now has two main focus projects: “Five Zeros”, and “100% Yield”. The five zeros are Zero New HIV infections (stopping sero-conversion through expanded VCT coverage and focused prevention programmes); Zero new-borns with HIV (effective PMTCT); Zero Opportunistic Infections (early detection, staging, support, care, management and treatment); Zero AIDS Deaths (early care-seeking, access to quality treatment); and Zero stigmatisation (treating HIV/AIDS as a chronic disease instead of as a socially-undesirable infection). The 100% Yields are 100% VCT uptake; 100% PMTCT; 100% detection and treatment of opportunistic infections; 100% access to ART; and 100% Community Mobilisation. The initial programmes focused on healthcare and nutrition, although the bakery was established in 1999 to provide more employment and income opportunities. The project initially did not operate within government programmes, but this has begun changing over time, and different government departments have begun supporting the initiatives. The HAART project has now received full accreditation from the National Department of Health. New government policies are also more in-line with the RAP process; and this has improved the relationship between the two. Thus, the project has a wide range of stakeholders, from community members, patients and staff, to government, and public and private donors. The main implementation was carried out by NMT; with in-kind assistance (training and resources) provided by a number of groups (listed under 4(d)).

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main objectives of the RAP are to provide high quality medical care in a holistic manner within the community; encourage capacity-building of community members; and conduct education, awareness-raising and de-stigmatisation initiatives. In order to provide high quality care within the community, the ATCs aim to provide all services in-house, rather than sending patients to other hospitals and clinics in the region. The ATCs therefore provide a wide-range of primary health-care, diagnosis and treatment programmes, as well as their own laboratory, x-ray and pharmacy services so that patients can receive all their diagnosis and treatment in one place. They also carry out follow-ups on all patients on long-term treatment to ensure treatment adherence. In order to improve the success rate of these initiatives, the programme also provides education on healthy living, including nutrition, hygiene and sanitation. This also includes information on the progression and treatment of illnesses, encouraging prevention, behavioural change, early treatment seeking, and treatment adherence, to help prevent illnesses from becoming serious or life-threatening. This also helps to reduce the burden on the clinic staff. To encourage capacity-building, RAP hires local community members to carry out most of their programmes, providing them with ongoing training and opportunities for sustainable livelihoods and generating an income. This includes VCT counsellors, home-based carers, and data capturers; a bakery, nappy factory and car wash; and SMME-development and assistance. Those who are unable to work (eg OVCs) are assisted in accessing social care grants; and provided with nutritional support, through feeding schemes and establishing food gardens. Community members are also provided with education and awareness-raising through public events, door-to-door visits, and education campaigns. De-stigmatisation campaigns are also conducted, to help reduce the social stigma attached to chronic illnesses like HIV and TB. This also ties in with information on the progression and treatment of illnesses.

b. What were the key development and implementation steps and the chronology? No more than 500 words
The Ndlovu Medical Centre was initially established in Elandsdoorn in Limpopo in 1994. It soon became apparent that simply running a medical centre would not be sufficient – initiatives needed to be developed to address some of the root causes of common illnesses in the area; as well as providing capacity-building opportunities for local community members. The first Nutritional Unit was opened in 1996, with three others opened in 2001, 2002 and 2004. The TB programme began in 1997, and was expanded with defaulter tracing in 2001; and contact tracing and community TB awareness in 2003. The first Aids Awarenss programme ran in 1998. The Maternity Clinic was started in 1999, and the Ndlovu Information Technology Training programme began in 2001. The dental care programme started in 2003. The HAART and PMTCT programmes were also initiated in that year. The mobile HAART programme for farm workers was established in 2004 in Mpumalanga and Gauteng; while VCT services began in 2005; and the OVC programme in 2006. The incinerator was developed over a number of years, and became operational in 2009. The first ATC satellite clinic was opened at Vaalwater in 2007, by the Waterberg Welfare Society. They were trained by NCG, and the ATC satellite was started to show the replication potential of the initiative. To underline this, the second ATC was opened in Lillydale in 2007; and the HAART programme was accredited with the Department of Health in 2009.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
One of the major problems facing the project is recruiting and retaining staff to work at the centres. Few professionals wish to work in remote rural clinics; and this hinders the capacity of the programmes. It is also sometimes difficult to train and retain local staff – many people would rather go look for work in the urban areas; and some will also leave the programme once they have been trained. The programme therefore aims to hire those members of the community who have a commitment to staying in the area. It has also often been difficult to maintain a good working relationship with government. Initially, the ATCs were not working within the government’s national programme, particularly as they were making ART available at a time when government was refusing to do so. Getting the required licences from government departments is also a lengthy process, and can often result in delays in treatment rollout for patients and community members. Thus, for some time the programme faced opposition from different government departments. Since then, the relationship has improved, although it is still difficult to maintain this as the government staff turnover is high. However, the project continuously strives to improve this relationship, and has even been chosen as one of the only NGOs to provide the Department of Health’s TB programme. There have also been difficulties in reducing the stigma attached to HIV and AIDS, meaning that some programmes focusing on this have not been supported by the community. However, through ongoing education and awareness-raising, the situation has improved, with more and more community members becoming involved, and voluntarily going for HIV testing and treatment.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The majority of the funding comes from local and international donors. The total expenditure in 2007 was roughly R37m spread throughout all the projects. Each project has its own budget and receives specific funding. USAID/PEPFAR committed funding until 2010 for the HAART programme, along with Virgin Unite, AngloCoal and Right to Care. Stichting Liberty funds PMTCT; while the Nelson Mandela Children’s Fund and Vodacom both support the nutritional units. The Royal Netherlands Embassy provides funds for the AIDS Awareness programmes. The EU and DFID also provide funding for the running costs of the Health, Childcare and Community Development Programmes. Sir Richard Branson funded the construction of the Bhubezi Care Group, after visiting the ATC at Elandsdoorn. The Department of Education supports pre-school development; while the Department of Health supports the integrated PHC/TB/HIV/AIDS Care programme. Department of Land Affairs supports the rural development; while the Department of Agriculture helps to fund the nutritional programmes. Two trusts were developed to help fund the project – the Ndlovu Medical Trust; and the Elandsdoorn Development Trust. The funding for the furnace was provided in the main by Ultrafurn (60%), while the remainder was supplied by Hugo Tempelman. The estimated cost for design and development is R3m. A number of organisations provided in-kind support. For example, Toga Laboratories provided containers to house the laboratories, as well as technical and logistical support. Sports Coach Outreach (SCORE) and Voluntary Service Organisation (VSO) conduct sports events to promote HIV awareness. The Universities of Utrecht, Berlin, Pretoria, and Witwatersrand have carried out ongoing research projects, which helps to increase the knowledge of target groups and build in-house capacity. Waterberg Welfare Society received training from NCG, and then implemented a satellite ATC site, to prove the effectiveness and potential for replication of the project. Foundation for Professional Develop (FPD) provided training for the VCT counsellors; and data capturers received training on electronic patient record management from the Department of Health. Originally, a large number of the staff came from overseas companies and organisations. However, this has changed over time, and now more than 90% of the 350 staff members at the Ndlovu Care Group are from the local community.

Is the initiative sustainable and transferable?
Although much of the funding is provided on three-year cycles, the majority of the funders have been involved for a number of years, and seem committed to continuing their involvement into the future. USAID/PEPFAR have committed funding until 2010. The project’s success has meant that funders want to stay involved. It has also started attracting government support and funding for the different projects. Thus, the project is likely to remain financially sustainable into the future. Because of the focus on capacity-building and education, it is also likely that the project will remain institutionally sustainable, as well as in personnel terms. One of the aims of the project is for the local community members to begin taking over the project in the future, and this increases both the community support, and its potential for sustainability. The focus on education also ensures that the impacts of the initiative are sustainable. By increasing awareness around disease progression and treatment, and reducing stigmatisation of HIV/AIDS, more people will get tested, seek early treatment, and hopefully aim for prevention. This could then help to reduce future HIV infections and deaths. The replication of the project has already been proved – a satellite centre has been established in Vaalwater; while four other RAPs are being developed. A second ATC was established in Lillydale; and a third (Nyathi) is under construction, and will hopefully be completed by the end of 2009. The project was also designed to be a best practice example for providing wide-ranging and effective medical treatment in rural areas, along with community empowerment, capacity-building, education and awareness-raising. Significant funding would be required to replicate the project on a similar scale – however, HIV/AIDS projects attract more funding than many other causes, and there is a large amount of funding available. Other projects could aim to only replicate certain aspects of the initiative (such as HAART; TB treatment; OVC programmes etc). This would reduce the costs of replication, but would also probably reduce the effectiveness of the intervention. Some political and community buy-in would also be necessary – each ATC aims to address the specific needs of the community, and negotiation with the community would be necessary. However, focusing on education, employment, and capacity-building may improve the likelihood of gaining community support. Considering the scale of health problems across rural areas of South Africa (especially the HIV and TB epidemics), such programmes are incredibly necessary and should be replicated in rural areas across the country. The effectiveness of this initiative and its potential for easy replication means that it is a good model for medical projects in other areas in the future.

What are the impact of your initiative and the lessons learned?
The first major impact of the initiative is that it brings effective and accessible healthcare to communities in deep rural areas. Local community members are able to receive a wide range of medical care, including primary healthcare, maternity care, HAART, PMTCT, TB diagnosis and treatment, and dental care. The project also provides employment opportunities for a large number of local community members, in an area where unemployment is high. By carrying out education, capacity-building and awareness-raising initiatives, the project can also help to improve the health of people in the community; and to reduce future infections and illnesses. The project has shown that initiatives in deep rural areas can work as effectively as hospitals in cities and developed countries. The model has been hugely successful, and has expanded to provide a wide range of services, even under difficult conditions. It has also achieved significant results in its treatment programmes, including a 0% MTCT rate since 2003. This shows that these goals can be achieved, throughout the country. The initiative has also already been replicated in other areas; and the project has partnered with the Department of Health to begin implementing its TB programme. Thus, it has also shown that effective partnerships, with both government and other sectors, can help to improve the impact of a programme


Institution Name:		Ndlovu Care Group
Institution Type:		Public Organization
Contact Person:		Mariette Slabbert
Title:		Chief Operations Officer
Telephone/ Fax:		+27 13 262 2263
Institution's / Project's Website:
E-mail:		mariettes@ndlovumc.org
Address:		PO Box 1508
Postal Code:		0470
City:		Groblersdal
State/Province:		Limpopo
Country:		South Africa

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information