An innovative health programme is thriving and making a difference in the lives of people in rural Eastern Cape communities. Sue Segar spent time with the project, walking with "nomakhayas" from house-to-house and taking a ferry trip across the Xhora river.
In a small thatched hut, halfway up a hill in the Wild Coast village of Nqileni, a young community health worker helps a frail, elderly man onto a portable scale. He suffered a stroke recently and has epilepsy, she explains, so it's important to check on him regularly and ensure he's taking his medication as prescribed.
While she assesses him, a second health worker speaks to the man's wife, who is holding a baby. She pulls a plastic bag, containing the family's clinic cards, from under a mattress.
Another health worker unpacks a pile of toys from a backpack and invites the baby's young aunt to join her on a mat on the floor with the baby. As they play, the health worker observes the baby to see how she's developing, and how she relates to her adult relatives. Next, they weigh the baby, measure her height and check that her immunisations are up to date.
There's an air of familiarity and trust as we sit in the one-roomed home the health workers visit regularly. They conducted ante-natal and post-natal visits to the baby's mother and monitored her mental wellness during and after her pregnancy; they offered breastfeeding support and monitored the baby's growth from birth.
We've walked a good twenty minutes to this homestead, between rolling, grass-covered hills scattered with neat, colorful huts, past a small flock of sheep and across a stream. In the distance is the sea. From one perspective its paradise here - paradise minus jobs and basic amenities such as roads.
I am accompanying the community health workers, known as nomakhayas, on their home-based care rounds for the Bulungula Incubator. The non-profit organisation, set up in the mid-2000s, works to build self-reliance in this rural community which has an unemployment rate of around 90 percent.
Nomakhayas - walking from house to house
Every day, Bulungula's team of 20 nomakhayas walk from house-to-house in Nqileni and the three surrounding villages - Mgojweni, Folokhwe and Tshezi - which comprise the Xhora Mouth administrative area.
The nomakhayas carry large backpacks which, they tell me, contain blood pressure and blood sugar machines, a scale, tape measures and the mid-upper arm circumference tape used to identify malnutrition, as well as pregnancy tests and condoms.
"Each nomakhaya goes out from 8 to 5 o'clock every weekday to assigned homes," says home-based care programme manager Bongezwa Maleyile. "We support people with chronic illnesses and do the screening at their homes. We check that they're adhering to medication. If we pick up that someone is unwell, we refer them to the Bulungula Health Point," she explains.
The nomakhayas have also been trained to help people with disabilities to overcome some of the barriers they face in such a remote community and have a "toolkit" to create awareness in the community about disabilities.
The nomakhayas also carry toys, used for Bulungula's early childhood development programme. Earlier in the day, I joined the nomakhayas at a play group in the village, where mothers of children under three bring them twice a week for two hours. The children stack blocks and fit shapes together, sing songs and engage with their peers.
While the children play, the health workers talk to the mothers, to check whether they have any problems, discuss health issues and keep tabs on the children's development.
"These play groups help build the relationship between mother and child. When they're older, we want them to be able to tell their mothers what they are going through," says Maleyile. "These village children have been playing together since they were tiny, like brothers and sisters."
A hub for numerous outreach programmes
The Bulungula Incubator's main office is located next to a preschool - one of five managed by Bulungula. The bustling building is the hub of a number of the incubator's local upliftment projects. Through a "preconception to career" approach, they run education and health and nutrition programmes, as well as promoting sustainable livelihoods.
Amidst the buzz of adult activity running the hub, the sounds of children's voices ring from the various rondavels housing the preschool classrooms; the smell of cooking comes from the kitchen in the main precinct - Bulungula provides daily nutritious hot meals, including vegetables grown in their own gardens, to all children and staff. The children receive regular growth monitoring as well as deworming and vitamin A supplements.
Besides the health outreach, the early childhood development programmes and the five preschools, they manage a primary school maths programme, while Bulungula College - with learners from more than 20 villages - is the area's first high school to offer matric as well as vocational education. They also run a radio station which broadcasts to more than 100 villages.
Bulungula Health Point
A few minute's walk away from the main office is the Bulungula Health Point, a Central Chronic Medicines Dispensing and Distribution pick-up point that was set up in 2021. Between 30 and 60 clients are seen at the health point per day. Residents can access medical care, collect their HIV treatment or be tested for the virus and have other screenings. It is staffed by two professional nurses and a mental health counsellor who are paid by the Bulungula Incubator with a contribution from the department of health. The nearest government clinic, Nkanya, is at least a two-hour walk from Nqileni and includes a ferry trip across the Xhora river, which cannot be crossed in heavy rain.
Stories abound about the struggles that patients faced before the Bulungula Health Point was set up. Maleyile, who grew up in Nqileni, recalls how, in 2021, pregnant, she woke up feeling unwell and went straight there. "They immediately picked up foetal distress and I was referred to Madwaleni Hospital, where I had an emergency C-section. If I'd walked to Nkanya, I would have lost my baby."
She continues: "Before we had the health point, it was not uncommon to see heavily pregnant women walking to Nkanya Clinic. Sometimes people would push them in wheelbarrows. It could take them a day to get there and back."
"A grandmother, who was HIV-positive, diabetic, and on hypertension meds, had to walk to the Nkanya Clinic to get her medication. It became more and more difficult for her to get there. I watched her health deteriorate as she started defaulting. It was not that she wanted to default on her medication; she just didn't have the energy in the end."
At the Bulungula Health Point, I meet the nurses in charge, as well as Stella Bili, a sessional nurse who runs a mobile outreach clinic to neighbouring villages. She says the facility has been a gamechanger in reducing the immunisation drop outs and high pregnancy rates that characterised the area before. Sister Bili stresses that the health point works "hand-in-hand" with the department of health, on a range of health campaigns.
A walk to the clinic
The next day, accompanied by a guide, we start the walk to Nkanya Clinic, which, for many years, was the closest clinic for the local villagers on this side of the Xhora river.
The nurses at the health point have asked us to take some blood samples across to the clinic which we carry in our backpacks. We make our way down a steep pathway towards the river.
Guide Yonwaba Olo, recalls how, when his grandfather became sick in 2009, he took him to the clinic in a wheelchair. "He couldn't walk ... I had to carry him from the wheelchair onto the boat. The side of the river is very muddy and he was worried his clothes would get dirty in the mud. It was slippery getting into the boat. On the other side of the river, we pushed him along the paths to the clinic."
The ferryman is waiting at the side of the river, sitting in a small rowing boat. With Olo translating, I ask him about some of his memories of rowing patients across the river. He recalls a time when a mother and a grandmother crossed the river, with the mother carrying a sick baby on her back.
"The baby was really struggling to breathe. I think the baby had asthma ... I wondered if the baby was even alive when they got off the ferry.
"Later that day, many hours later, they returned, without the baby. They left the body behind. I felt very sad for that mother and grandmother."
Once across the river, we walk in the heat through the hills, past many homesteads. After an hour and a half we reach a dirt road. We cross another stream with a small bridge over it and, a few kilometres further we reach Nkanya Clinic.
Clinic manager Keka Soldati greets us warmly and takes the blood samples. She explains that Nkanya works closely with the Bulungula Health Point. "They've taken a huge load off us," she says. "The work we are doing together is saving many lives."
Where it all started
Bulungula co-founder Dave Martin, describes himself as a "general McGyver" at the incubator.
Twenty two years ago, after graduating with a Bachelor of Business Science from the University of Cape Town, Martin says he travelled on public transport through Africa to London, worked in the IT sector in the UK for three years, before travelling around Asia and South America for another two years. But all he wanted to do was return to South Africa and live in a Xhosa village.
As the head of the student-run NGO the Students' Health and Welfare Centre's Organisation, in his final year at UCT, he'd decided that his passion was not finance but community development.
"In my holidays, I'd jump on a bus and head north into east and central Africa. During those travels I realised my real love, where I felt most at home, was the rural African village life."
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On his return from his travels, in 2002, he says he walked the beach, from Kei Mouth to Port St Johns on South Africa's Wild Coast, looking for a place to call home and to start a community development enterprise. "I had this idea to use tourism as a tool for community development in the rural areas," he says.
Halfway into his walk, he found a derelict building and negotiated with the community, the local government and the then Department of Land Affairs for a permit to start a tourism lodge.
"The Bulungula Lodge - a joint venture between the community and myself - opened in 2004. I ran it for ten years, till 2014 and then I gave my share of the business to the community," says Martin.
Not long after he moved to Nqileni, Martin met his wife Rejane Woodroffe in Cape Town. She is a financial analyst and economist who is also Bulungula's executive director.
Bulungula Lodge expands to bigger projects
The Bulungula Lodge was doing well, creating jobs and winning awards for community development, but the couple soon realised there was more work to be done in Nqileni and beyond.
Woodroffe continues the story: "In 2006, a third of the babies in this village died of diarrhea. It was a very significant event. We had to do something, so we started raising money for water tanks.
"That same year, a local mud school, No-Ofisi Primary, collapsed, so we started raising money for a classroom.
"We realised we needed a non-profit entity to start doing all this work. I was still working in the finance industry and we put in some of our own money and registered a non-profit organisation. We raised about R250 000 in seed funding and grew from there.
"We went from the crisis response to the water, to the education situation and then we opened the first preschools. Then the home-based care came and as we were trying to solve the next problem, we encountered all the primary school gaps. Then there was no high school so Bulungula College came. There was no grand plan, it all just happened over time," says Woodroffe.
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Today, they have 130 permanent staff members and 50 interns - about 180 people - on the payroll, working on the various programmes on education, health, vibrant villages, sustainable livelihoods and farming. "We cook almost 1000 hot meals a day. It is quite an operation and our budget is around R20 million a year which we have to fundraise for."
And to raise funds, it is important to show the incubator's impact. Bulungula has implemented a tablet-based data collection system which the nomakhayas also use. All the information captured synchs with a database that helps measure the impact of their projects, taking into account that a single individual can benefit from several of the incubator's initiatives. "A lot of people are interested in learning from our person-centred data model," says Woodroffe.
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'Our relationship with the department is excellent'
Turning to the Bulungula Health Point, Woodroffe says it has been one of the real gamechangers for the community. The health point started when somebody donated a hut for them to run HIV support groups. "The community loved what was happening so they built a small building using their own money and physical labour. We started running various health services and home-based care services, then eventually we hired a nurse, and added more and more services. Today it is fully renovated, has two fulltime nurses, an outreach nurse, mobile bus, it has a mental health component and it has a memorandum of understanding with the [health] department."
"Our relationship with the department is excellent. They cover about 60 to 70 percent of the costs of our health programme now," says Woodroffe. "What we've achieved here would have been totally unimaginable without the help of the government. They come here and they give us free medication, even though we are not even an officially registered clinic; they offer training for our nurses and our nomakhayas and they help us wherever they can."
Martin is adamant that the success of the Bulungula Health Point would have been impossible without the ongoing support from local health officials, their "can do" attitude, and the strong bond of trust that has built up between Bulungula, the community, and the department.
"A lot of the officials were once nurses ... I am regularly blown away by their passion to make a difference in these communities," he says.
Defending government for not having built more clinics in the area, Martin continues: "How many clinics should there be in a place like this where it is just village after village after village, all needing roads? The roads are a huge challenge. The challenge of the former Transkei is real in terms of the spatial set up. It's not just a story of corrupt officials who don't care or incompetent officials who do care but can't do the job.
"The only way through it is to have this partnership approach where we realise there are limited resources and we're all in it together. That's what we've got going in this part of the world and what we need on a national level," he says.
'Things are getting better'
"I guess when you see progress, like we do, massively, here ... it makes one believe things are getting better. Even if one looks beyond one's small community and looks further afield in the rural areas like ours ... as you drive around you see that in 2004, the closest electricity wire to us was almost 30 kms away. That's where the electricity grid ended. Now as you drive through the villages, every single village has electricity. Similarly taps, and toilets. You see better schools, much better housing.
"Even looking at other metrics round poverty and national statistics, I am not being naïve, and I know one can see the deterioration, particularly in some of the big metros like Joburg ... at the same time, the narrative that everything is falling apart is inaccurate.
"We need much more balanced reporting on what is happening in the country," Martin says. "If one has that more balanced view, there are lots of reasons to be optimistic," he adds.
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