About 15km east of Mthatha in the rural Eastern Cape is the Coffee Bay turn-off; a good tar road with busy petrol stations, shops and businesses.

After 70km further on the smooth tar road take a left on to a narrow winding gravel road. Be wary of the Transkei Big Five (dogs, sheep, cattle, donkeys, pigs) and the car while driving. Cross the bridge over the Mthatha River and climb up steep hillsides speckled with colourful huts and grazing livestock. After about 30 minutes take a right at a T-junction, and follow the signs for Mdumbi.

Mdumbi village is right on the coastline and is home to the Mdumbi Backpackers; a place frequented by “off the beaten path” travellers. Mankosi village is about 3km inland from Mdumbi.

After driving up and over a steep hill, a large white building sits on top of a hill just on the right. Red and blue lettering spell “Mankosi Clinic”. There are no cars outside the building, nor any sign of prospective patients one would expect to see at a clinic. The bright lettering and building should be a beacon of hope for this community, but now serves as an obnoxious reminder of broken promises.

A community for its own future

Nowayitile Nyakombi, Mankosi Community Member: “From the beginning when we had an idea of building this clinic we had a big vision of seeing this clinic operating. Having nurses, nurses that will be based here all the time like 24 hours. So if there is anything that is happening they can quickly rush to the clinic, that is what I want to see.” Image courtesy of Image courtesy of Kathryn Cleary.

Siphokazi Dyantyi* is 25 years old, and has lived in Mankosi village her entire life. Dyantyi told Spotlight that in 2010 the community came together to build its own clinic, “simply because of the distances that they travel to the nearest clinic”. Along with support from Dutch funders and a local NGO named Transcape, Mankosi sold sand to raise money to build the clinic.

“Mankosi community is very independent,” she said. “It’s a community building its own future.”

Dyantyi estimated that roughly 3,000 people lived in the village, part of the OR Tambo District.

A mobile government clinic visits Mankosi once a month, but residents say the services provided are not enough.

The Pilani Clinic is 7km back on the winding gravel road. Dyantyi estimated it can take up to three hours to walk there and the closest hospital, Canzibe, is roughly 30km away. Dyantyi stated that the only public transport residents have to these facilities is a bus that leaves at 5am, and most residents then walk back.

There are no ambulances that serve Mankosi, and with few residents owning vehicles, accessing these health facilities can be a nightmare.

Sibongile Masiso was born and raised in Mankosi and now works at the Mdumbi Backpackers. Since 2003, Masiso has been driving community members to and from clinics and hospitals as a result of no EMS services. Masiso keeps track of his call-outs in a small book. Image courtesy of Kathryn Cleary.

One resident has taken the community’s plight into his own hands. After a cholera outbreak in 2003, Sibongile Masiso took it upon himself to drive community members to the hospital at low-cost. Dyantyi said that hiring a private vehicle can cost up to R800 one way, while Masiso’s service is significantly more affordable.

“The problem is we don’t have (an) ambulance here”, said Masiso. “So I am using my car.”

“‘[For] those who are pregnant or sick. It’s lots!”, he emphasised. “Sometimes they call me at 12 in the evening and then I have to drive them.”

Masiso keeps track of the calls he responds to in a small book, and notes the reason for the emergency. Some of the reasons include “sick”, “stabbed”, “baby sick”, “mother”, or “GB” for giving birth. The majority of calls are noted “mother” or “sick”.

“Some deliver babies in the car”, said Masiso. He added that birthing complications were common in the community, and Dyantyi agreed.

When Masiso is unavailable, the community suffers.

“Years ago I had a friend who was stabbed, and Sibongile was not available”, said Dyantyi. “The wound was near his heart.”

Dyantyi found someone to drive, and accompanied her friend to Canzibe. They arrived around midnight. “The condition of the person was really, really bad”, she said.

“There were no nurses, no doctors, the only person there was a community health worker.”

“It was just blood everywhere!”

Dyantyi recalled that it took two hours for a doctor to arrive, but her friend’s condition had quickly deteriorated – he needed to go to Mthatha.

At 4am, Dyantyi’s friend was taken by ambulance to Mthatha. “At that time he was already gasping, you could see that this person was going to die at any moment,” she said.

Despite a transfusion, Dyantyi’s friend had lost too much blood and later died at Nelson Mandela Hospital.

“Most of the people in this community that pass away all die on the way to hospital”, said Dyantyi.

“I want to stop using my car because the road is bad,” said Masiso. “But I am afraid people are going to die and then they will blame me.”

“That’s why I keep on taking them,” he said.

“Many communities in the Eastern Cape face the same problem,” said Thoko Mtsolongo, Eastern Cape Health Crisis Action Coalition co-ordinator.

“In response to a report on emergency medical services produced by the South African Human Rights Commission in October 2015, the department said that it is had purchased 141 new vehicles. However it has emerged that more than half of its 419 ambulances were reported in the depot unused because of minor faults during the last financial year.

“The department, by its own estimates, should have 667 ambulances but in effect there are only about 200 ambulances on the road servicing one of South Africa’s most vast provinces. It is extremely worrying because many have never seen ambulances in their villages and people die unnecessarily.”

It started in 2010

Masiso is part of the Mankosi Clinic Committee, and has been actively involved since 2010.

“People keep asking me when is the clinic going to open and I keep saying ‘I don’t know, I don’t know’.”

“Maybe someone can just come with a plan,” he said shaking his head. “I’ve been asking and asking, making phone calls, and I don’t know.”

“If the government can open Mankosi clinic I will be really happy,” said Dyantyi. “Some of the pregnant mothers lose their babies because of the long distance.”

Liyabona Ntsunguzi, Mankosi Community Member: “What I want to see happening with this clinic is for the government to open it officially; to have nurses working, to have medication and all the resources that are being used at a health facility. Also the fact that they could work during the night, this is what I would like to see happening at the clinic.” Image courtesy of Kathryn Cleary.

Multiple sources told Spotlight that in 2010 there was a verbal and written agreement between the Mankosi community and the Eastern Cape Department of Health. The agreement was for the Department to run the clinic once it was built — however no proof of this agreement can be found.

In June 2016 the Department of Public Works inspected the clinic and held a meeting with the Mankosi community. Minutes from the inspection meeting state that the document detailing the results of the inspection was reportedly given to the Nyandeni sub-district clinic manager.

“[They] agreed that [they] received this but is not sure where it is on [their] desk,” state the minutes.

According to the register, the sub-district clinic manager was not in attendance at the meeting.

The meeting concluded with an agreement by Department of Health officials to submit a report on the clinic to Bhisho (the health department headquarters); including of photos and comprehensive notes.

“The way forward is that [Department of Health official] will submit the report to Bhisho, [sub-district clinic manager] will submit the Public Works document again and the DoH will report back to the Mankosi Community within a week,” state the minutes.

More than two years later, the Mankosi Clinic remains empty; the community left in the dark, and the smell of fresh paint permeates the emptiness that has yet to see a patient.

Despite numerous attempts by Spotlight, the Department of Health failed to respond for comment on the matter.

Mankosi as a microcosm

In June of this year, Minister of Health Dr Aaron Motsoaledi assured the South African public that the health system was not collapsing. He argued that the country was still able to manage HIV treatment for the majority of the population. Despite Motsoaledi’s sentiments, rural communities like Mankosi feel the neglect.

Data collected in 2017 stated that Mankosi had a 22% HIV infection rate, but with clinics and hospitals far from the community, residents battle to get life-saving medication.

Dyantyi said that in 2017 the Pilani Clinic was out of ARVs for almost three months. Spotlight later confirmed this information with a source.

“The clinic orders [medicines] but the clinic does not have a set date when the order will be delivered,” the source said. “That’s the biggest challenge.”

Masiso said that on 22 October he visited Pilani for his young daughter, but could not receive the appropriate medication.

“Sometimes Pilani just has Panado, no medicines,” said Masiso. “Allergex and Panado.”

Data shown to Spotlight from 2016 reveals that more than half (60%) of patient’s using Pilani Clinic were from Mankosi. This data stems from a headcount that took place at the clinic.

A source later provided a shocking list of Pilani clinic’s current stock-outs which included FDCs (fixed-dose combination ARVs), children’s antibiotics, Betadine ointment and adult paracetamol.

The source added that the clinic also suffered from a severe shortage of staff. However, stock-outs and staff shortages in rural clinics and hospitals are nothing new.

Spotlight spoke to a staff member at Zithulele Hospital, who explained how rural communities often felt the failures of the healthcare system the worst. Zithulele is perceived by Mankosi residents to be the best hospital in the area, but is almost two hours away by car. As a result, residents are often referred to Canzibe unless otherwise requested.

The staff member highlighted that the most common health concerns in the area were HIV, TB, child and maternal health issues — “the rural health big four”.

They emphasised the need to recruit “long-term staff” and to prioritise “team-building” at rural facilities.

“There is no quick fix,” they said. “We need to build momentum in the healthcare system,” the staff member said. “We need to be asking ourselves, how can we be making this better.”

Call to action

Rural Health Advocacy Project health systems and policy programme manager Russell Rensburg said that the Eastern Cape had a problem with resource distribution. “One of the challenges is the proliferation of district hospitals and the under-investment in primary healthcare,” said Rensburg.

“At the core you can’t solve the problem by looking at one aspect, you have to look at the Eastern Cape as a system.”

Rural Health Advocacy Project project co-ordinator, Mafoko Phomane, spoke about the disconnect within the province between sub-district and district management levels. Phomane outlined that the clinics were managed by the sub-district, while hospitals were managed by the district.

“There’s a disconnect in terms of referral,” said Phomane. “Ultimately that is what causes dysfunction with primary healthcare and district services, and the Eastern Cape is worse because of the distances and roads.”

“To me the big story is the under-investment in Pilani Clinic,” said Rensburg. “Because Pilani doesn’t have the equipment and staff to do the outreach they need.”

“If they were better capacitated and able to work in partnership with Mankosi it would solve the problem.”

“A quick-win would be the partnership between Pilani and Mankosi, how best can Pilani be resourced in order to support Mankosi,” said Phomane. “It’s not impossible, whereas staffing Mankosi is almost impossible knowing the HRH (human resources for health) and budget constraints.” DM

* Names have been changed to protect the identity of the source

** Pilani is alternatively spelled Philani

Kathryn Cleary is a health journalist with Grocott’s Mail in Makhanda, Eastern Cape and was commissioned by Spotlight to write this article.