versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.101 no.12 Cape Town Dez. 2011
Nurture grassroots human capital and save lives - global award finalist
Imagine the Western Cape's R64 million health budget under-spend (2010/2011) being redirected into one tightly knit, strategic unit of social entrepreneurs, NGOs and public sector specialists tasked with growing primary healthcare capacity in burgeoning underserved urban areas.
Now picture that being replicated across the country where a quick glance at under-spending in other far less efficient provinces seems to render the Western Cape's apparent incapacity (they treated 15.8 million people at primary healthcare clinics the previous financial year, boasting the country's highest TB cure rate at 79.4%), virtually insignificant. That's the kind of 'out the box' thinking that resulted in long-time social change/ empowerment volunteer, Dr Keith Wimble, becoming one of two finalists to represent South Africa in Vodafone's Graham Maher 'Change the world' volunteerism award. The prize would have netted R1.2 million for the Cape Peninsula-wide Ikamva Labantu (Xhosa for 'Future of the people') healthcare NGO where he's currently placed (he was narrowly beaten last month by Santi Kotze, a Brits speech therapist working with children with severe physical and mental disabilities after running neck and neck with her in a nation-wide public poll). While the concept of a specialist team with finely tuned skill-sets spending money that could otherwise go back to Treasury (not to mention perhaps being allocated funds officially clawed back from among the larger billions misspent or stolen in public sector healthcare) is still a pipe-dream, Wimble has already found influential, willing partners. In his first six months of working at Ikamva Labantu, he's met with and found like-minded souls in Western Cape Health MEC, Theuns Botha, and Provincial Premier, Helen Zille, and helped facilitate workshops on healthcare collaboration/partnerships. Ikamva Labantu looks after 13 000 orphans and vulnerable children, 300 'at risk' youths and 600 elderly people. While slowly rolling out a chain of Wellness Centres in the main townships across the Peninsula (one established in Khayelitsha and another building under conversion in Guguletu) as the bedrock for community-orientated primary healthcare (COPHC), Wimble plugged into the political movers and shakers. Last month, a leading accounting firm presented the concept of commercial partnerships to Botha, municipal health officials and their NGO counterparts.
Wimble, a 17-year veteran of community upliftment (he's a former CEO of arguably the oldest and most credible NGO in South Africa, the Valley Trust at Botha's Hill in KwaZulu-Natal's Valley of a Thousand Hills), says the meeting was a 'revelation' to him. 'I had never attended a meeting organised by an MEC that has not been a "tell" meeting [i.e. being told what will be happening]. This was different. There were a dozen options for service providers to review and develop variations of a template to suit their businesses or skill sets. The innovative concept to open funding mechanisms for the department was followed by a presentation that clearly showed how the province was not coping with the burden of disease with the endless stream of people migrating to the Western Cape from the Eastern Cape and African countries north of the Limpopo,' he said. (The province's population grew by 16.7% between 2001 and 2007, according to census figures.) The new strategy addressed the nation-wide reality that non-communicable diseases such as diabetes, hypertension, obesity, heart attacks and strokes collectively kill more people than HIV/AIDS - with Botha stating unequivocally that his priority going forward was 'wellness' (in line with national health minister, Dr Aaron Motsoaledi's 'back to basics' preventive approach). 'I smiled for the rest of the day,' said Wimble, a successful Pietermaritzburg entrepreneur who downscaled his lucrative businesses to enable him to devote his life to humanitarian healthcare.
Seek out and nurture grassroots rural leadership
His experience in the harsh KwaZulu-Natal thornveld has left him with a passionate conviction that unless effective leaders and role models are created and supported to grapple with the problems of their own communities, primary healthcare delivery stands little chance - let alone building a universal healthcare coverage system upon it. Listening to Motsoaledi speak of spending R250 billion over the next 15 years on national health insurance when the national health department could not even manage its last budget, posting over R4 billion in irregular expenditure, 'frankly scares the hell out of me,' says Wimble.
'We should be getting those on the ground re-acquainted with primary healthcare, community health workers in the field with health education ... Intersectoral collaboration, a founding principle of primary healthcare, scarcely exists [i.e. sanitation, roads and communication]. The health department should be the referee, not the primary implementer,' he believes. He says rural community leaders (mainly ageing traditional leaders with low levels of literacy) need incentivised retirement to make way for younger people supported by intensive education and mentoring if pervasive patriarchy, subservience and low self-worth are to be overcome. Although traditional leaders are recognised in the Constitution, there is no clear role laid out for them in local government. Additionally, 'most have no vision for their own areas and can only present a wish list of the infrastructure required'. Rarely is there a development initiative for the human capital within communities, nor is a contribution from the community planned. 'An entitlement mentality is not a characteristic of a leader. They tend not to expect better unless it is provided for them,' he says. Wimble parodied the dependency syndrome by describing a junior clerk typing up an official requisition form for new corrugated iron roof-sheeting as rainwater dripped onto his desk, comparing it with the first hospital management 'decentralisation bible' circulated in 1995.
South Africa lost its way on primary health care
'It was a tome of note on how hospital management was going to be rolled out. But one comment stuck in my mind which sums it all up and that was this: "No action without permission". Now that's exactly the issue. Unless you give those at the bottom the authority to make decisions it just doesn't work ... successful big corporations all do this,' he added. Wimble said that in his first few years at Valley Trust (from 1994 onwards) 'everybody in the health department' attended workshops on primary healthcare. 'Today if you ask nurses about primary healthcare they can't tell you because HIV came along and the focus shifted to that and integrated management of childhood illnesses.' The great irony and tragedy was that pioneers of COPHC (early 1950s), Drs Sydney and Emilie Kark at Pholela Mission in KwaZulu-Natal and Valley Trust founder, Dr Halley Stott, were largely ignored until now. Within a decade of setting up a clinic at Botha's Hill on the boundary between black and white South Africa, Stott had won the trust of locals and reduced infant mortality from 164 to 22 per 1 000.
'He did some very basic things; taught the community about organic agriculture, focused on food preparation and a balanced diet and paid attention to mother and child issues such as long-term breast feeding and immunisation - that's how simple it was,' Wimble says, shaking his head ruefully at the modern tendency to 'chase CAT scans and telemedicine'.
When Vodacom South Africa advertised for volunteers in their local 'Change the world' project, he had just completed setting up a major ARV programme at the Catholic Centocow Mission Hospital near Ixopo in KwaZulu-Natal while raising over R1 million for soccer fields and a tennis court. The sports facilities now see up to 600 schoolchildren using them daily - but have no toilets to support them. Wimble used his well-exercised lateral thinking to suggest to Vodacom in his competition entry that they pay the six-month R120 000 'salary' for individual volunteers to Centocow Mission for the toilets. Duly chosen, Vodacom spurned his suggestion for a volunteer posting to an NGO called 'One thousand community health workers' in Inchanga near his old Valley Trust stomping ground - and instead posted him to Khayelitsha for Ikamva Labantu. Now that the six-month stint has been extended to 31 March next year for all 10 of the national contenders, Wimble has pledged the next R120 000 to Centocow as well. 'I gave Father Ignatius at Centocow Mission my word, so the posting down to Cape Town, 1 000 km from home, became part of that commitment - even though I'd never worked in a township shack environment before,' he adds.
Sponsored volunteerism requires sacrifice; the longer the tune lasts, the longer you pay the piper. However, one upside to Wimble's coming second is that he won't have to spend another year working with his sponsor-designated NGO, something Kotze will be contractually bound to if she goes on to win the Graham Maher Award. 'I have a home and business in Hilton, so winning had a bit of a sting in the tail, though it would have been a huge honour and benefit for the people I'm working with,' he says with a stoicism born of constantly witnessing people surviving intense hardship.