New hope for health in South Africa

Abstract

The recent removal of South African Health Minister Manto Tshabalala-Msimang from her post has been universally welcomed. Her replacement has been named as anti-apartheid veteran Barbara Hogan, marking the start of a desperately needed new era. Clare Kapp reports from Cape Town.Within hours of taking office on Sept 25, South Africa's new president Kgalema Motlanthe signalled a clear break from ousted President Thabo Mbeki and announced that Health Minister Manto Tshabalala-Msimang would be moved to a lesser government post. The news was greeted with spontaneous celebrations. AIDS activists threw a joyous party outside parliament and then serenaded the new minister, Barbara Hogan, in front of her home. “The public is expecting to see real change. We need to see our health system back on track”, declared Hogan after the swearing-in ceremony of the new Cabinet.Hogan is an anti-apartheid veteran who joined the banned African National Congress (ANC) in 1976. She was detained in 1982, held in solitary confinement for a year, and sentenced to 10 years for high treason. She was released in 1990 and became a member of parliament after democratic elections in 1994. According to the Treatment Action Campaign, Hogan was one of the few ranking ANC lawmakers to speak out against Mbeki's stance on HIV/AIDS. In February, 2003, she received a Treatment Action Campaign memorandum calling on Mbeki to rollout treatment and in retribution was removed as chair of the parliamentary finance portfolio committee. François Venter of the Reproductive Health and HIV Research Unit at the University of Witwatersrand said that, despite Hogan's lack of health experience, she was “one of the most competent people we could have hoped for”.“We have had a decade of obstruction and HIV denialism from Mbeki and Tshabalala-Msimang”, Venter told The Lancet. In addition to the estimated 5·4 million people infected with HIV/AIDS, South Africa has some of the world's worst outcomes of other health indicators, including maternal and infant mortality and tuberculosis, he said. “The health minister refused to accept that there was even a problem in these areas, never mind take responsibility. I think all health-care workers and patients have breathed a huge sigh of relief at her going”, said Venter. There was also a general welcome for the nomination of a former provincial health minister, Molefi Sefularo as deputy health minister to fill the gap following last year's axing of Nozizwe Madlala-Routledge, who incurred the ire of the presidency by lambasting conditions in public hospitals and because of her close links with HIV/AIDS activists.In her annual budget speech to parliament in June, Tshabalala-Msimang claimed the “fragmented, inequitable, and disjointed” system she inherited 9 years ago was now “unified and integrated”. She said more than 101 million patients had access to primary-care services in 2007/8 compared with 67 million in 1998, and the total public sector health budget rose from 29·3 billion rands in 2001/2 to 53·2 billion rands in 2007/8. Some 84% of children younger than 1 year were now immunised and there were plans to introduce pneumococcal conjugate and rotavirus vaccines to reduce deaths from diarrhoea and pneumonia, she said.But her legacy is dubious at best. There is a glaring gap between the semi-luxurious private sector which accounts for more than 56% of health expenditure for 7 million people and operates independently of the overstretched public sector which serves 40 million people. Tshabalala-Msimang put forward draft legislation earlier this year to rein in costs and fees in the private sector but it was shelved, and there is no national health insurance scheme. At a meeting on Sept 22, Tshabalala-Msimang said she was “quite happy” with the performance of 31 clinics and hospitals assessed for their “core standards” including safety, clinical care, governance, and infrastructure, but did not release the promised full report.The opposition Democratic Alliance called on the new minister to improve skills and training of hospital managers. It cited the example of the Eastern Cape province's Frere Hospital, at the centre of allegations about the poor quality of care and an abnormally high number of infant deaths. It also called on Hogan to act on one of Tshabalala-Msimang's biggest complaints—the human resource crisis, which has left 46 000 vacant nursing positions and 9700 vacant doctor and specialist positions in the public sector.Despite its high public-health expenditure, The Lancet's Countdown to 2015 special issue showed South Africa to be one of the ten countries making least progress towards the Millennium Development Goals (MDGs) on reducing child mortality. It said the mortality rate for children younger than 5 years had risen from 60 to 69 deaths per 1000 livebirths between 1990 and 2006, and that HIV/AIDS was responsible for 57% of these deaths. The Every Death Counts report compiled for the Countdown series said at least 260 women, babies, and children died every day for lack of targeted, high impact interventions and national leadership. Tshabalala-Msimang challenged the statistics and insisted that the nation was on track to achieve the MDGs.The minister never shook off labels like “Dr Garlic” and “Dr Beetroot” for preaching the virtues of nutrition rather than antiretrovirals. At the 2006 AIDS conference in Toronto, she became an international embarrassment, putting garlic and lemons on the South African stand. The former UN envoy for AIDS in Africa, Stephen Lewis, said her policies were “worthy of a lunatic fringe”. Her attempts to gain final approval of new medicines recently failed, to the relief of many health activists (see panel).PanelSouth Africa's Medicines BillOne of Manto Tshabalala-Msimang's last tasks as Health Minister was to steer the Medicines and Related Substances Amendment Bill through parliament, establishing a new Regulatory Authority for Health Products to replace the ineffective and slow Medicines Control Council (MCC).Tshabalala-Msimang said the new authority would have a permanent chief executive officer and more staff and resources than the existing MCC and would close loopholes by covering traditional and complementary medicines. But she voiced disappointment that parliament's health portfolio committee had rejected proposals which would have allowed the minister to act in “the public interest” and have the final say in approving new medicines and clinical trials. Instead, parliament decided that approval for new medicines should be based purely on quality, efficacy and safety—the international norm. “We remain concerned that the people of this country are going to be left exposed to products that are not in their best interests”, Tshabalala-Msimang insisted.The health committee, which like parliament is dominated by the ruling African National Congress, initially threw out the two-tier proposal but then performed an embarrassing U-turn. Opposition Democratic Alliance health spokesman Mike Waters said this was after intervention from Tshabalala-Msimang. On the last day of deliberations the controversial clause was finally dropped.The bill passed through the National Assembly on Sept 23, the same day that parliament approved the resignation of President Thabo Mbeki and 2 days before Tshabalala-Msimang was removed as Health Minister. It still has to be rubber-stamped by the National Council of Provinces.South Africa now has the world's biggest antiretroviral treatment programme, with more than 450 000 patients receiving therapy by the end of February. But critics said the success was despite Tshabalala-Msimang rather than because of her, as was the provision of dual therapy for the prevention of mother-to-child-transmission of HIV/AIDS, which was only approved nationally this year—4 years after being recommended by WHO.South Africa's National Strategic Plan for HIV/AIDS, drafted while Tshabalala-Msimang was on sick leave last year, aims to provide care and treatment to 80% of those in need by 2011 and halve the number of new infections. Nearly 1000 people are estimated to die each day of HIV/AIDS related diseases and the number of new infections is even higher, outstripping the number able to access treatment. Tshabalala-Msimang said the most recent Antenatal Survey showed that HIV/AIDS prevalence decreased from 29·2% in 2006 to 28·0% in 2007, which indicated a “trend of decreasing prevalence overall”. But epidemiologists queried the methodology.One of Hogan's most immediate challenges will be to improve the integration of treatment for HIV and tuberculosis given that 60% of tuberculosis patients have HIV/AIDS. There were 2901 reported cases of multidrug-resistant (MDR) tuberculosis in South Africa last year, and 561 cases of extensively drug-resistant (XDR) tuberculosis, but this is believed to be a gross underestimation. Tshabalala-Msimang downplayed the crisis despite violent breakouts by highly infectious patients from isolation units. The health department wants to spend more money on beds for MDR and XDR tuberculosis cases, but is struggling to find staff for the wards.Motlanthe is regarded as a caretaker president until national elections early next year, which are expected to put ANC leader Jacob Zuma in power. Zuma was acquitted of raping an HIV positive friend in 2006 but conceded that he had unprotected sex and showered afterwards to reduce the risk and so faces huge pressure to prove that he is serious about tackling HIV/AIDS. Tshabalala-Msimang put a brave face on her demotion and said that, as minister without portfolio in the presidency, she would “continue to add value” to the government's work. Much of the country disagreed. “Tens of thousands of South Africans have lost their lives because of her ridiculous policies on HIV/AIDS”, said the Democratic Alliance. “She should have been fired 9 years ago.” The recent removal of South African Health Minister Manto Tshabalala-Msimang from her post has been universally welcomed. Her replacement has been named as anti-apartheid veteran Barbara Hogan, marking the start of a desperately needed new era. Clare Kapp reports from Cape Town. Within hours of taking office on Sept 25, South Africa's new president Kgalema Motlanthe signalled a clear break from ousted President Thabo Mbeki and announced that Health Minister Manto Tshabalala-Msimang would be moved to a lesser government post. The news was greeted with spontaneous celebrations. AIDS activists threw a joyous party outside parliament and then serenaded the new minister, Barbara Hogan, in front of her home. “The public is expecting to see real change. We need to see our health system back on track”, declared Hogan after the swearing-in ceremony of the new Cabinet. Hogan is an anti-apartheid veteran who joined the banned African National Congress (ANC) in 1976. She was detained in 1982, held in solitary confinement for a year, and sentenced to 10 years for high treason. She was released in 1990 and became a member of parliament after democratic elections in 1994. According to the Treatment Action Campaign, Hogan was one of the few ranking ANC lawmakers to speak out against Mbeki's stance on HIV/AIDS. In February, 2003, she received a Treatment Action Campaign memorandum calling on Mbeki to rollout treatment and in retribution was removed as chair of the parliamentary finance portfolio committee. François Venter of the Reproductive Health and HIV Research Unit at the University of Witwatersrand said that, despite Hogan's lack of health experience, she was “one of the most competent people we could have hoped for”. “We have had a decade of obstruction and HIV denialism from Mbeki and Tshabalala-Msimang”, Venter told The Lancet. In addition to the estimated 5·4 million people infected with HIV/AIDS, South Africa has some of the world's worst outcomes of other health indicators, including maternal and infant mortality and tuberculosis, he said. “The health minister refused to accept that there was even a problem in these areas, never mind take responsibility. I think all health-care workers and patients have breathed a huge sigh of relief at her going”, said Venter. There was also a general welcome for the nomination of a former provincial health minister, Molefi Sefularo as deputy health minister to fill the gap following last year's axing of Nozizwe Madlala-Routledge, who incurred the ire of the presidency by lambasting conditions in public hospitals and because of her close links with HIV/AIDS activists. In her annual budget speech to parliament in June, Tshabalala-Msimang claimed the “fragmented, inequitable, and disjointed” system she inherited 9 years ago was now “unified and integrated”. She said more than 101 million patients had access to primary-care services in 2007/8 compared with 67 million in 1998, and the total public sector health budget rose from 29·3 billion rands in 2001/2 to 53·2 billion rands in 2007/8. Some 84% of children younger than 1 year were now immunised and there were plans to introduce pneumococcal conjugate and rotavirus vaccines to reduce deaths from diarrhoea and pneumonia, she said. But her legacy is dubious at best. There is a glaring gap between the semi-luxurious private sector which accounts for more than 56% of health expenditure for 7 million people and operates independently of the overstretched public sector which serves 40 million people. Tshabalala-Msimang put forward draft legislation earlier this year to rein in costs and fees in the private sector but it was shelved, and there is no national health insurance scheme. At a meeting on Sept 22, Tshabalala-Msimang said she was “quite happy” with the performance of 31 clinics and hospitals assessed for their “core standards” including safety, clinical care, governance, and infrastructure, but did not release the promised full report. The opposition Democratic Alliance called on the new minister to improve skills and training of hospital managers. It cited the example of the Eastern Cape province's Frere Hospital, at the centre of allegations about the poor quality of care and an abnormally high number of infant deaths. It also called on Hogan to act on one of Tshabalala-Msimang's biggest complaints—the human resource crisis, which has left 46 000 vacant nursing positions and 9700 vacant doctor and specialist positions in the public sector. Despite its high public-health expenditure, The Lancet's Countdown to 2015 special issue showed South Africa to be one of the ten countries making least progress towards the Millennium Development Goals (MDGs) on reducing child mortality. It said the mortality rate for children younger than 5 years had risen from 60 to 69 deaths per 1000 livebirths between 1990 and 2006, and that HIV/AIDS was responsible for 57% of these deaths. The Every Death Counts report compiled for the Countdown series said at least 260 women, babies, and children died every day for lack of targeted, high impact interventions and national leadership. Tshabalala-Msimang challenged the statistics and insisted that the nation was on track to achieve the MDGs. The minister never shook off labels like “Dr Garlic” and “Dr Beetroot” for preaching the virtues of nutrition rather than antiretrovirals. At the 2006 AIDS conference in Toronto, she became an international embarrassment, putting garlic and lemons on the South African stand. The former UN envoy for AIDS in Africa, Stephen Lewis, said her policies were “worthy of a lunatic fringe”. Her attempts to gain final approval of new medicines recently failed, to the relief of many health activists (see panel). One of Manto Tshabalala-Msimang's last tasks as Health Minister was to steer the Medicines and Related Substances Amendment Bill through parliament, establishing a new Regulatory Authority for Health Products to replace the ineffective and slow Medicines Control Council (MCC).Tshabalala-Msimang said the new authority would have a permanent chief executive officer and more staff and resources than the existing MCC and would close loopholes by covering traditional and complementary medicines. But she voiced disappointment that parliament's health portfolio committee had rejected proposals which would have allowed the minister to act in “the public interest” and have the final say in approving new medicines and clinical trials. Instead, parliament decided that approval for new medicines should be based purely on quality, efficacy and safety—the international norm. “We remain concerned that the people of this country are going to be left exposed to products that are not in their best interests”, Tshabalala-Msimang insisted.The health committee, which like parliament is dominated by the ruling African National Congress, initially threw out the two-tier proposal but then performed an embarrassing U-turn. Opposition Democratic Alliance health spokesman Mike Waters said this was after intervention from Tshabalala-Msimang. On the last day of deliberations the controversial clause was finally dropped.The bill passed through the National Assembly on Sept 23, the same day that parliament approved the resignation of President Thabo Mbeki and 2 days before Tshabalala-Msimang was removed as Health Minister. It still has to be rubber-stamped by the National Council of Provinces. One of Manto Tshabalala-Msimang's last tasks as Health Minister was to steer the Medicines and Related Substances Amendment Bill through parliament, establishing a new Regulatory Authority for Health Products to replace the ineffective and slow Medicines Control Council (MCC). Tshabalala-Msimang said the new authority would have a permanent chief executive officer and more staff and resources than the existing MCC and would close loopholes by covering traditional and complementary medicines. But she voiced disappointment that parliament's health portfolio committee had rejected proposals which would have allowed the minister to act in “the public interest” and have the final say in approving new medicines and clinical trials. Instead, parliament decided that approval for new medicines should be based purely on quality, efficacy and safety—the international norm. “We remain concerned that the people of this country are going to be left exposed to products that are not in their best interests”, Tshabalala-Msimang insisted. The health committee, which like parliament is dominated by the ruling African National Congress, initially threw out the two-tier proposal but then performed an embarrassing U-turn. Opposition Democratic Alliance health spokesman Mike Waters said this was after intervention from Tshabalala-Msimang. On the last day of deliberations the controversial clause was finally dropped. The bill passed through the National Assembly on Sept 23, the same day that parliament approved the resignation of President Thabo Mbeki and 2 days before Tshabalala-Msimang was removed as Health Minister. It still has to be rubber-stamped by the National Council of Provinces. South Africa now has the world's biggest antiretroviral treatment programme, with more than 450 000 patients receiving therapy by the end of February. But critics said the success was despite Tshabalala-Msimang rather than because of her, as was the provision of dual therapy for the prevention of mother-to-child-transmission of HIV/AIDS, which was only approved nationally this year—4 years after being recommended by WHO. South Africa's National Strategic Plan for HIV/AIDS, drafted while Tshabalala-Msimang was on sick leave last year, aims to provide care and treatment to 80% of those in need by 2011 and halve the number of new infections. Nearly 1000 people are estimated to die each day of HIV/AIDS related diseases and the number of new infections is even higher, outstripping the number able to access treatment. Tshabalala-Msimang said the most recent Antenatal Survey showed that HIV/AIDS prevalence decreased from 29·2% in 2006 to 28·0% in 2007, which indicated a “trend of decreasing prevalence overall”. But epidemiologists queried the methodology. One of Hogan's most immediate challenges will be to improve the integration of treatment for HIV and tuberculosis given that 60% of tuberculosis patients have HIV/AIDS. There were 2901 reported cases of multidrug-resistant (MDR) tuberculosis in South Africa last year, and 561 cases of extensively drug-resistant (XDR) tuberculosis, but this is believed to be a gross underestimation. Tshabalala-Msimang downplayed the crisis despite violent breakouts by highly infectious patients from isolation units. The health department wants to spend more money on beds for MDR and XDR tuberculosis cases, but is struggling to find staff for the wards. Motlanthe is regarded as a caretaker president until national elections early next year, which are expected to put ANC leader Jacob Zuma in power. Zuma was acquitted of raping an HIV positive friend in 2006 but conceded that he had unprotected sex and showered afterwards to reduce the risk and so faces huge pressure to prove that he is serious about tackling HIV/AIDS. Tshabalala-Msimang put a brave face on her demotion and said that, as minister without portfolio in the presidency, she would “continue to add value” to the government's work. Much of the country disagreed. “Tens of thousands of South Africans have lost their lives because of her ridiculous policies on HIV/AIDS”, said the Democratic Alliance. “She should have been fired 9 years ago.”