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Bambisanani Home Based
Care Program in Region E, Eastern Cape
Langa, a mineworker from Region E, decided
to test for HIV after participating in the National Union
of Mineworkers program. Langa was shocked to discover he was
infected. He was encouraging his co-workers to use condoms
when they visit local women for sex, and many of them listened.
Langa was hesitant to tell his wife Nothembile about his HIV
status, but realized that he must. When he returned home on
leave, he accompanied Nothembile to the clinic for an HIV
test; it came back positive, and the couple was advised to
test their six-month old baby as well. The baby, Vuyani, tested
positive.
Langa decided to stay at home when Nothembile
and Vuyani became ill and appreciated the help of Nothembile's
directly observed treatment short-course (DOTS) supporter,
a volunteer from the community who visits every day to give
her tuberculosis medicine. With help from the EQUITY Project
partners and the Bambisanani initiative, Langa was put in
touch with a local official who gave Nothembile a home-care
kit containing linen savers, soap, rehydration solution, gauze,
Vaseline, Betadine, gentian violet, calamine lotion, gloves,
and pain tablets. The kit helps make Nothembile comfortable
as her condition worsens. Langa knows he cannot return to
work at the mine. He is comforted to know that he can be trained
for new work, such as bread baking, by the Mineworker's Development
Agency.
Langa often lies awake at night, worrying.
However, he is thankful for local initiatives, made possible
through the Bambisanani partnership, which are helping him
to deal with the burden of AIDS.
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Community Health Workers
and Tuberculosis
The community health workers began by singing
beautiful songs they use to inform the community about tuberculosis
(TB) and HIV ("DOTS, direct observation and treatment,
is what we need to do…"). Amidst a neighborhood
of abject poverty, the community health workers (CHWs) greeted
their neighbors as they walked to visit patients recovering
from TB to give them their medication and check on their general
health. One woman was alone in her small, one-room tin house.
The walls were covered with newspaper and there was one small
bed. This woman told the CHWs that she had moved there from
the countryside so that she could be near the local clinic
and receive her TB medication.
This is just one of many stories that illustrates
the EQUITY Project's impact in destitute areas. It also illustrates
the real need addressed by several hundred CHWs serving throughout
the Eastern Cape Province. Each CHW received training in basic
health promotion and visits patients five days a week. In
the coming years, the EQUITY Project will continue to work
with CHWs in delivering primary health care services. As their
knowledge of health problems expands, so does that of their
clients.
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Livestock Sales in the Eastern Cape Province
In FY 2000 USAID launched an agribusiness
linkage project, AGRILINK, in the Eastern Cape region of South
Africa. Designed to enhance markets and skills for rural farmers
through linkages with larger agribusiness, AGRILINK has demonstrated
encouraging initial results. Twenty percent of South Africa's
cattle herd, or 2.6 million head of cattle, are being raised
in the Eastern Cape. Of that, over 1.7 million head of the
total production in the Eastern Cape comes from black farmers
in the communal areas. As a result, ARGILINK immediately focused
on cattle production as one of the primary agricultural activities
in the province. Prior to the AGRILINK, there was no organized
system of stock sales in rural areas. Farmers transported
cattle long distances to infrequent auctions with fixed prices.
Animals arrived in poor condition, transport was expensive,
and the auctioneers offered very low nonnegotiable prices.
This resulted in rural livestock producers deciding not to
market animals, over-grazing of land, and the nonparticipation
of many thousands of black farmers in the local economy. Poverty
in these areas was enhanced and land degradation compounded.
The AGRILINK project began on October 2000
conducting a series of livestock sales in the rural farming
communities of the Eastern Cape province. These AGRILINK facilitated
stock sales institutionalized regular competitive bi-monthly
cattle sales throughout most of the rural areas within the
Eastern Cape for the first time. This has brought an increasing
number of buyers directly in contact with black stock farmers
to purchase their animals. In January 2001, AGRILINK collaborated
with auctioneers and established livestock buyers such as
the Stock Owners Association of South Africa to publish a
calendar of stock sale sites throughout the province for the
next year. This further standardized the newly established
rural livestock marketing channel to even the most remote
areas of the province. These institutionalized stock markets
have led to: a) higher prices paid to the emerging farmer
for cattle and other livestock; b) larger numbers of animals
sold from within the communal and rural areas; c) reduction
of overgrazing and environmental degradation on communal lands;
d) reduced cost for transport of animals; and e) payment made
with uncrossed checks allowing for more efficient banking.
There have been other interesting spin-offs
of the stock sales. Construction of stock pens at two new
locations nearer the markets of the communal lands to facilitate
future sales were completed with private sector funds. Black
South Africans have been encouraged to and are participating
as cattle buyers on a much larger scale. Stock sales are used
to educate farmers on livestock disease control. At every
auction, the AGRILINK team invites veterinary officers from
pharmaceutical companies to advise on disease control and
treatment. Due to the success of these sales, the Agricultural
Research Council has donated 10 Nguni stud bulls to the AGRILINK
project, which will be distributed to livestock farmers associations
with breeding programs and linkages to the AGRILINK facilitated
stock sales.
As of February 2001, the AGRILINK team facilitated
37 stock sales at which 2,920 cattle were sold. Over 1,300
farmers, 179 of which are women, benefited from this marketing
channel. The total income earned by emerging black farmers
from sale of their livestock through stock sales has been
to date R3.4 million (US$450,000).
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Evidence of Declining STD Prevalence
in a South African
Mining Community Following a Core Group Intervention
(Summarized from an article by R Steen,
B Vuylsteke, T De Coito, S Ralepeli, et al)
By building partnerships and measuring results,
the Lesedi HIV/AIDS Prevention Project has translated initial
success into a formula for sustainability in South Africa's
mining communities. The women of Virginia, a mining community
in the Free State Province of South Africa, call the project
"Lesedi," which means, "We have seen the light."
Once suspicious of the free diagnosis and treatment of sexually
transmitted infections (STIs) the project offers, the women
now embrace it as their own. In just three years, Lesedi has
grown from a small pilot of an innovative intervention to
a full-fledged project with strong financial and moral support
from the public and private sectors.
Partners in an ongoing effort to replicate
the intervention first tested in Virginia in other South African
mining communities include Harmony Gold Mining Company Ltd.,
Goldfields Ltd., Joel Mine, the local branch of the National
Union of Miners, and the local, state and national health
departments. These partners on the Lesedi Steering Committee
are working, for example, to expand the Lesedi Project's STI
and HIV prevention services to more communities surrounding
the mines of Harmony Gold Mining. "This project has dramatically
reduced sexually transmitted diseases and forms a key part
of our overall HIV/AIDS strategy," noted Mr. Bernard
Swanepoel, chief executive officer of Harmony Gold Mining
Company Ltd.
Union leaders are also enthusiastic about
the project. Sethoke Mahemu, chairperson of the Harmony branch
of the National Union of Mineworkers, recalls that there was
some initial resistance among workers until they experienced
tangible improvements in their health and productivity, such
as fewer days of work lost due to illness and fewer visits
to the mine's medical stations. "It has worked so perfectly
that results can be seen by all," said Mahemu. "We
as the Harmony branch support this project wholeheartedly."
Mining companies, like other businesses, generally
do not provide healthcare services for people other than employees
and their dependents. It was therefore essential to demonstrate
to mine management that a community intervention was in the
immediate interest of the company. Evaluation of the program
showed that among women using the service, the prevalence
of the most common curable STIs dropped by as much as 85 percent
in nine months. Screening during routine annual examinations
revealed a 43 percent lower rate of gonorrhea or chlamydial
infection and 78 percent fewer genital ulcers among miners.
In addition, the results of the monitoring at mine medical
stations suggest that proximity to the intervention site reduced
a miner's risk of acquiring an STI. Although data on HIV were
not available, estimates of how these reductions in STIs affected
HIV transmission were developed using a probability-based
computer model. The model estimated that providing periodic
presumptive STI treatment and peer education to 400 women
had averted 40 HIV infections among the women and 195 HIV
infections among the larger group of miners. The model was
also used to develop simple cost-benefit calculations comparing
the cost of the intervention to the potential savings in medical
costs due to averted HIV infections. The result-an estimated
savings of $US539,630 to the mining company.
In three years of implementation, Lesedi's
approach to community-based STI prevention and treatment for
women at high risk of infection has developed from a small
pilot project to a self-sustaining intervention that is being
replicated in mining communities and other areas with similar
transmission dynamics. Several elements have contributed to
this success. First, a careful analysis of the situation guided
the initial response. Its findings suggested that a similarly
comprehensive approach was required to reduce STIs. This meant
identifying and involving marginalized groups (sex workers
and other women at risk in the community) who had previously
been neglected in the solution.
From the beginning, the project sought to
include all interested parties in order to build a broad base
of support. For example, the support of the unions was critical.
Union leaders explained the objectives of the intervention
to the miners and obtained their cooperation and support for
the examinations that were an important component of the evaluation.
Union support also helped the project maintain a positive
image and prevent discrimination towards women using the services.
The project maintained close communication with the departments
of health at several levels. Briefings with local health authorities
helped keep them informed and made it easier to coordinate
referrals. Provincial and national health department representatives
were consulted early and played important roles in resolving
regulatory issues, identifying sources of support, and facilitating
the exchange of information among mining projects. Participatory
planning and sound financial controls became increasingly
important as the project expanded and more stakeholders became
involved. A planning committee now meets regularly, and meeting
minutes are circulated to all committee members. Annual project
and financial reports ensure transparency and accountability.
Because the pilot intervention employed new
approaches, care was taken to collect the data that would
be needed to evaluate it and interest potential stakeholders.
"Process indicators," such as numbers of peer educator
referrals and clinic attendance figures, served as measures
of the operational efficiency of different aspects of the
intervention. Outcome measures, including reported condom
use and STI rates among women receiving project services,
were used to document the immediate benefits of the intervention
to its direct beneficiaries. Perhaps most important, additional
effort was made to demonstrate public health impact by collecting
data on STI rates among miners. This last element, supplemented
by modeled estimates of averted HIV infections and cost-benefit
analysis, was probably most instrumental in ensuring continued
support and expansion of the intervention.
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