Christine is providing migrant and residential farm workers in rural areas in South Africa with a set of on-site integrated health solutions, especially related to HIV/AIDS, by employing a peer-to-peer caregiving structure that reinforces behavior change towards a positive lifestyle. This is done in parallel to the building of a working environment that is conducive to the acceptance of their health condition both by their peers and their employers.
The New Idea
Agriculture is considered one of the main industries providing employment to the majority of the labor force in rural areas of South Africa. Many people in rural areas are employed on farms either as permanent or seasonal workers providing unskilled labor to the farmers. Almost 85% of people employed on the farms migrate on a daily basis from rural communities as far as more than 100 km away from the farms. This makes it difficult for those that are HIV positive to access decent health and support services on a regular basis from health centers in their communities since they spend the whole day on the farms, leaving home around 4:30 am and coming back around 7 pm. Christine has developed a practical solution for reaching out to the farm workers on site with effective, reliable and regular healthcare solutions on HIV/AIDS and other related diseases. Through her organization, Hlokomela Training Trust (HTT), Christine makes sure that HIV positive farm workers are able to access medication and support services on-site and during working hours consistently and conveniently to ensure their wellness and positive living.
Hlokomela’s entry point is the establishment of HIV/AIDS clinics that are conveniently accessible to farm workers. The clinics are staffed with professional healthcare workers and provide all basic HIV/AIDS services including Voluntary Counselling and Testing (VCT), administering Anti-Retroviral Treatment (ART), counseling, nutrition and all round wellness services. HTT also has an outreach program through mobile clinics to ensure that workers even from distant farms and game reserves are accessing the services conveniently. One of Christine’s strongest innovations is in the way she has incorporated into her idea a peer caregiving strategy that influences behavior change on the farms and ensures integral wellness of farm workers that are HIV positive. Each farm has a caregiver called Nompilo (meaning “one who brings life”) who is a farm worker selected by the farm workers themselves and acts as a pivotal figure responsible for the health and wellness of their colleagues. These Nompilos are trained in relevant courses to equip them with the knowledge and leadership skills to effectively assume their roles. The Nompilos initiate behavior change in their fellow workers to reduce the spread of HIV and eliminate stigmatization both from other workers on the farm, community members and the farm managers. They are responsible to ensure that workers regularly go for VCT and practice safe sex and also reduce the rate of defaulting on ART.
Nompilos are at the core of Christine’s model in linking the farm workers, the farm owners/manager and HTT and together provide a holistic inside-out caregiving structure for migrant farm workers. They also represent their colleagues to the farm managers on labor issues relating to HIV/AIDS care (like negotiating for sick leave to go for check-up). Therefore, Christine is also working to improve the working conditions of farm workers by brokering relationships between farm workers and the farm owners. Christine realizes that the strained and poor working conditions for farm workers on most farms contribute to the deterioration of the farm workers’ health especially those that are HIV positive and this has a direct negative impact on overall productivity on the farms. This is based on the concept that a satisfied worker in good health is the most valuable asset to increase productivity.
Christine is currently reaching out to about 12,000 farm workers on more than 69 farms and game reserves, through a network of about 70 Nompilos. HTT has negotiated for a revised work place policy with assistance from the International Organisation for Migration which has now been adopted on 65 farms around Hoedspruit. Further, low HIV prevalence have been reported on the farms where Christine works: currently at 29% as compared to the average prevalence rate of 40% for farm workers in South Africa. She is now ready for national spread and is negotiating a partnership with the government’s department of health which wants to adopt her model and scale out to other farms beyond the Limpopo province. She is also seeing early adoption of her model in neighboring Lesotho.
The rate of HIV/AIDS prevalence among farm workers in rural areas of South Africa is very high. Estimates indicate that an average 40% of people from rural areas (statistics for Limpopo and Mpumalanga provinces) employed as farm workers were HIV positive as of 2010 as compared to the national average prevalence rate of 18.1%, which includes rural and urban (International Organization for Migration, 2010). This is because people in rural areas in general lack proper knowledge and education on the prevention of HIV resulting in risky behaviors that accelerate the spread of HIV infections. This is more so for farm workers who have problems accessing HIV/AIDS care services provided in their communities consistently and conveniently because of their migrant nature. The farm workers are ferried on buses from their communities (as far as a 3-hour drive) as early as 4:30 am and only get back home around 7 pm. This means they do not have time to visit clinics for services like VCT, counseling, general check-ups and ARV refills.
Another problem faced by farm workers that are HIV positive relates to stigmatization and discrimination both from their fellow workers and farm owners and managers. Lack of proper knowledge and information on HIV/AIDS and also the inherent perceptions about sexually transmitted diseases, especially in rural areas, leads to segregation and emotional suffering for people that are infected and this deteriorates their health even more. This becomes more evident if the infected people are immigrants (mostly from Zimbabwe, Malawi and Mozambique) as there is already a history of xenophobia towards foreigners. On the other hand, people that look like they are suffering from AIDS would be refused employment (or even fired if already employed) by farmers as they are associated with low productivity.
Further, South Africa has a history of poor working relationships between farm workers and farmers which stems from the Apartheid era. Farmers are known to ill-treat their workers not caring for their wellness and working conditions and usually pushing for production through cheap labor. On the other hand, farm workers tend to have a defiant spirit and look at the farmers as oppressors which also leads to stressful working environment on the farms. Based on this sour relationship most farmers would refuse their workers sick leave to visit the clinics (even for ART refills or required check-ups) and they would be marked absent without pay or even get fired if it is repeated. Most workers would then choose to abscond on clinic visits and default on ART than lose their precious jobs which would further deteriorate their health. A survey by Médecins Sans Frontières (MSF) in 2012 reports that migrant farm workers are three times more likely to default on ART within 3-6 months of the treatment than other populations within the same area. Therefore, the stressful working conditions lead to rapid deterioration of their health and some of them end up dying prematurely or losing their jobs because they can no longer cope and this negatively impacts on the living standards of their families.
The government, through the Department of Health has failed to effectively reach out to migrant farm workers with convenient and accessible HIV/AIDS services because of lack of capacity to create a holistic model that targets the underlying problems above. On the other hand, other development organizations that work with farm workers on HIV/AIDS have created models that fail to penetrate the farms and reach out to the individuals influencing behavior change and creating cohesion between the workers and the employers. Although access to HIV/AIDS is the underlying problem, most organizations ignore the need to transform the farm into conducive working environment linked to the communities where workers feel accepted and at home both by their peers and also the management. HIV positive farm workers therefore lack an all-round support system stemming from the workplace to their families and communities to ensure that they live stress free health lives and are able to keep their jobs and sustain their livelihoods.
Christine’s model is based on a number of programs which together grant its uniqueness in providing support and services to HIV/AIDS infected migrant farm workers, their colleagues as well as their families. HTT runs three stationery clinics which provide medical, counselling and support services as well as administering of ARVs to farm workers in Maruleng. From the clinics, regular mobile clinic outreach programs are organized to distant farms and game reserves where the patients are seen on site. This is in collaboration with Nompilos and farm management who ensure that the workers are given some time during the day to attend the clinic. The clinics are well staffed by qualified medical personnel (nurses, counsellors, doctors) and are regularly inspected by public health authorities for adherence to necessary quality standards. The clinics benefit on average 1,000 people per month with various HIV/AIDS care services. Some of the farm workers benefiting from HTT are international migrants mainly from Mozambique, Zimbabwe and Malawi who constantly migrate to and from their counties of origin especially during off-season. Christine developed a health passport where each individual’s medical history is recorded and this accompanies the farm workers wherever they go. This ensures that any health service provider they consult with is able to follow their history and provide the relevant treatment at any given time.
To get people to come and access the services at the clinics was initially a big problem because of issues of stigma, discrimination and bad working policy such that Christine realized that there was the need to infiltrate the farms and work from inside through people that would be accepted and respected by the workers. This is where the idea of injecting a peer care giving model through Nompilos was created. Christine approaches the farm workers (with permission from the farmers) and encourages them to elect a Nompilo who would be their caregiver. Although anyone can be chosen, mostly the Nompilos would themselves be HIV positive. The Nompilos are then trained to enable them to understand their role and also to equip them with knowledge and skills on issues surrounding HIV/AIDS, counseling, hygiene, nutrition, and general physical and emotional wellness to empower them to be able to handle their responsibilities. HTT pays the Nompilos a modest stipend to cover other expenses and also to provide motivation for them to be dedicated to their role. The Nompilos organize workshop trainings through HTT to reinforce information about HIV/AIDS and how it can be prevented or managed. They also conduct on the job one-on-one talks with their colleagues to ensure that workers are informed about HIV and also to reduce stigma and discrimination. HTT does not dictate the actual behavior change strategies used by Nompilos, but encourages them to come up with creative strategies than will be effective on each farm. The Nompilos also monitor the health status of each worker and offer advice and encouragement to seek necessary attention like tuberculosis screening, VCT, general medical check-up, etc. The Nompilos also organize leisure on-farm activities during tea and lunch break where the workers have time to relax and bond while performing traditional dances, playing football or traditional games. The Nompilos also extend their roles to the communities where the workers come from (as they also tend to be from the same communities) with home visits to teach the whole family issues around nutrition, hygiene and positive living. Leisure activities are also organized in the communities for the workers and their families even off-season to maintain team work and acceptance of people that are HIV positive. Overall the Nompilos act like social workers both on the farms and in the communities, with a higher level of respect and acceptance by their colleagues than someone from outside.
Another angle of the idea involves brokering labor relations between the farmers and the workers. Christine has negotiated with management from 65 farms around Hoedspruit to develop a workplace policy that benefits both the employers and the employees. The farmers are committed to abide by the policy and agree to a number of conditions that make it easy for the workers to access HIV/AIDS services from HTT clinics at the same time they would benefit from less absenteeism through sickness and deaths, and thereby improving production. The farmers through the policy agree to allow workers visit the clinics when necessary giving them reasonable amount of time, and the Nompilos ensure that the workers do not abuse this agreement. The farmers also agree not to discriminate against any HIV positive individual but rather accommodate them in a more appropriate job that would not negatively affect their health. The farmers, Nompilos and HTT meet once a year (during the Annual General Meeting) to discuss issues related to workplace policy and how they can resolve challenges that come up. Christine has also put in place non-compulsory annual and pre-employment medical check-ups for every hiring season. The workers benefit from knowing their health status and how to take care of themselves better not only on HIV/AIDS but also other diseases like hypertension, diabetes, asthma, etc. The medical reports are made available to the farmers (except on their HIV status) and they benefit in knowing how to place the workers in appropriate jobs to maximize productivity. The farmers are under an agreement not to discriminate against any person suffering from any ailments in hiring, unless they are medically unfit to cope in any of the jobs on the farm and this is discussed with HTT and the Nompilos. Although this is not compulsory, almost 70% of the workers choose to do HIV testing during the medical trails each season.
By recognizing that there is also the underlying symbolic problem of stigmatization at play, Christine complements the model with communication strategies and advocacy through events, brochures, graffiti and the print media to create awareness of HIV/AIDS prevention, treatment and also behavior change. Christine also manages a nutrition program which includes an HTT’s vegetable garden and a food bank where farmers donate various food items from their stock and these are given out as parcels to patients that have nutrition challenges. Further, HTT manages a herbal garden and sells the products to supermarkets in Hoedspruit, and together with proceeds from a second-hand clothes shop, they supplement income for financial sustainability on top of donor funding. HTT also has crèches on the farms where workers who cannot leave their kids at home bring them to be looked after by child minders during working hours.
Through this multi-faceted strategy, HTT has managed to reduce HIV/aids prevalence on the farms she works with from over 40% to less than 29%. Only two babies have so far been born HIV positive from the farm workers on these partner farms which now have over 70% adherence to ART treatment through HTT. This translates from the behavior change on the farms and an increase in knowledge and understanding of HIV/AIDS issues and also convenient access to treatment. Christine is now engaging the government’s Department of Health in scaling the model to other farms – and now also mines – beyond Maruleng through a partnership where the government would fund the spread of hundreds of Nompilos on the farms and mines through HTT. Working with the International Organization of Migration, Christine has taken the model to other farms in Mpumalanga, North West and Western Cape provinces training and coordinating Nompilos on the farms as pillars for HIV/AIDS care for migrant farm workers. Christine has also developed an operation guideline for the model which is being used as best practice in Lesotho and also in the mining sector in Mozambique, facing a similar challenge of migrant workers and influx of sex workers especially along the Maputo road corridor. Christine is in the process of developing a partnership with Paul Matthew an Ashoka Fellow who created an organization called North Star Alliance, working to provide HIV/AIDS care to mobile truck drivers and sex workers in hotspots along busy road networks to have peer educators (Nompilos) for sex workers in the hotspots.
Christine was born in a family of health workers, her father a general medicine practitioner and her mother a professional nurse. Christine’s parents served disadvantaged communities mainly comprising of farm workers employed in surrounding farms and interacting with people from these communities almost on daily basis helped her understand at a very early age social challenges encountered by rural farm workers and their families. Christine encountered the disparities in social classes in South Africa at an early age and was specifically concerned with children in orphanages that had no homes. At 11 years of age (in grade 4), Christine started organizing small events (dancing and singing concerts) and raised money which was donated to orphanages in disadvantaged communities. Later, Christine studied nursing and worked as a professional psychiatry nurse in the government and retired after 25 years of service. Throughout her career, Christine continued helping the poor and less advantaged through various charitable activities, specifically reaching out to farm workers and their communities
In 1990, Christine moved to Hoedspruit, Limpopo, following her husband who had bought a Mango fruit farm. She continued interacting with farm workers in surrounding farms and this is when she realized that they did not have access to proper and convenient health services on the farms. She then managed to get a license from the government to practice as a private health practitioner and negotiated with one of the farm owners to let her start a clinic to extend general health care to the farm workers. She extended her practice to 5 clinics on 5 different farms from 1990 to 2002. Through this practice, Christine realized that most of the people on her register (as patients) were dying from HIV-related illnesses and they did not even know about their positive status. Struck by the high levels of ignorance of HIV/AIDS, the risky sexual behavior most of them were practicing and the stigma against people that look like they are suffering from AIDS, she came up with the idea of developing an integrated healthcare model for farm workers. She started working on the idea with funds from her private practice and in 2005 registered HTT as a CSO and incorporated the idea of Nompilos to strengthen the behavior change aspect of her model.