This article was published in Business Day.
Posted to the web on: 19 September 2006
How the health minister hurts SA
MANTO Tshabalala-Msimang's failure to manage the treatment of AIDS is well known. She has promoted pseudoscientific remedies and undermined the antiretroviral (ARV) rollout. SA is not even in the top 10 in Africa for the proportion of people in need of ARVs who actually receive them - that is if we are to believe government's treatment statistics. The programme is so poorly monitored that no one knows with any confidence how many people receive treatment. However, Tshabalala-Msimang has also failed on other critical aspects of her job, including AIDS prevention, TB management and adequately resourcing the health system. She has even failed at the one campaign she claims to champion: nutrition. She has undermined the independence of both the Medicines Control Council and the Medical Research Council (MRC) as well as shown contempt for the courts and the constitution. During her term, many clinics and hospitals have moved to the brink of collapse. Life expectancy has plummeted; deaths among infants and young adults - especially women - have soared.
The cabinet has emphasised prevention as the cornerstone of government's AIDS policy. Yet, the mother-to-child transmission prevention programme is implemented poorly. It has been inadequately monitored and evaluated, so we have little understanding of how effective it is. Except for Western Cape, all provinces continue to use the suboptimal single-dose nevirapine regimen. The paediatric HIV epidemic could be eliminated swiftly, but there is no political will to do so.
Accessing postexposure prophylaxis after rape is challenging. Even health workers complain that accessing this programme is difficult following occupational injuries.
Few schools implement adequate sex-education programmes or make condoms available. Government-funded condom promotion campaigns are practically invisible. The Khomanani AIDS awareness programme is in limbo. The health department's plan to deal with HIV prevention expired at the end of 2005.
As a consequence of HIV, the TB epidemic has exploded in the past decade. TB is the biggest recorded cause of death in SA. The minister spurned efforts years ago to form a coalition against TB. That she discouraged officials from attending the MRC-organised meeting to deal with the XDR TB outbreak should alone be grounds for dismissal.
Many public health care workers in SA are doing a phenomenal job, against all odds, to give the best care they can to their patients. They are the seldom-recognised heroes of the HIV epidemic. Yet the minister's dereliction of duty shows utter contempt for them.
A Human Sciences Research Council survey has shown the poor state of health worker morale, caused primarily by the increase in workload due to AIDS as well as high levels of HIV infection among nurses. The South African Health Review shows that the number of nurses per public sector users has declined during the minister's term. So have other key medical personnel ratios. Many nurses and doctors have left the public sector either for the private sector or overseas. Many of our hospitals are in a dire mess. Patients have to queue in township clinics before sunrise and spend the whole day navigating the system. Yet the health department's framework human resources plan is devoid of concrete measures to address this.
The minister has created the illusion that she is addressing nutrition. But telling people to eat garlic, lemons and African potatoes to ward off disease is pseudoscience, not nutrition. Food insecurity is indeed a serious problem. Ensuring that unemployed people have access to healthy food, either through social grants or food parcels, is far more important than prescribing the contents of their salads. A Joint Civil Society Monitoring Forum report from 2005 demonstrated the inadequacy of the health department's nutrition interventions. Further, not a single scientifically accurate fact sheet on nutrition and HIV for the public has been issued by the department. Between the minister's rhetoric and implementation there is a huge gulf.
Ultimately, President Thabo Mbeki has to take responsibility for Tshabalala-Msimang's failures. But it is not too late to address the crises in our health system. Firing the minister will not fix the problems, but it would be an important start. The president can signify his commitment to resolving the decline in South African health care by dismissing Tshabalala-Msimang and replacing her with someone competent and less arrogant, who understands science and deals fairly with civil society.
Geffen is the policy co-ordinator for the Treatment Action Campaign.