Health minister is clearly a minister in poor health

February 16, 2007
I take no pleasure in seeing Health Minister Manto Tshabalala-Msimang ill. Outshone by colleagues who were brimming with good health at a cabinet cluster briefing in Cape Town yesterday, Tshabalala-Msimang became an object of pity and embarrassment.

This was not Dr Beetroot, or the Mad Hatter - to be ridiculed and sniggered at. This was a woman who was disorientated and who spoke with difficulty.

The briefing was bound to be a headache for government officials, who had always dreaded Tshabalala-Msimang's antics at press conferences, especially when asked questions about HIV and Aids nutrition, beetroot and the African potato.

Then there was her combative perfor-mance in Toronto in 2006, which also prompted her colleagues to insist on a change in communication strategy. But yesterday was different. It appeared things had got worse. Reading from a statement, she lost her place and, on one occasion, had to be assisted by Housing Minister Lindiwe Sisulu.

Questions had to be repeated, while others were totally misunderstood. As the chairman of the cluster, for example, an erratic Tshabalala-Msimang directed a question about Bok van Blerk's song De La Rey to her director-general, instead of Arts and Culture Minister Pallo Jordan.

Laughter quickly smothered embarrassment.

When asked a question about extreme drug re- sistant TB that her officials had anticipated, she rambled on at length from a prepared reply that did not directly answer the question asked.

And then there was the question of whether she would follow in the footsteps of her deputy and some health MECs, and take a public HIV test.

Tshabalala-Msimang, who completed her medical studies in the Soviet Union, decided to throw in a Russian phrase, as unintelligible to most of us in the audience as some of her replies.

Later, after the ordeal was over, she was spotted giving a brief jig, as if to say, "I'm fit and healthy", before leaving the venue.

Was it government policy on everyone's lips after yesterday's briefing? Nothing of the sort. "What is wrong with Manto?" was the phrase on many lips.

Tshabalala-Msimang has always been the subject of gossip in the corridors of power and she has her more vocal detractors who have called for her head because they disagree with her position on HIV/ Aids. There has been speculation about the reasons for her incoherence and, if these are correct, she is not alone in the executive.

I don't know whether any of it is true. What I do know is that President Thabo Mbeki is not the type to get rid of cabinet ministers who are ill, even if they are on their death beds.

I once sat next to transport minister Dullah Omar on a National Assembly front bench. I watched him collapse before me and thought he was dead. He was helped out of the chamber, a frail old man. Public works minister Stella Sigcau, too, was often more at hospital than at work, but the president remained loyal to his colleagues, ensuring they con- tinued to receive a salary for life. Both died in office.

Tshabalala-Msimang's health continues to be a source of speculation.Last week, the Sunday Times reported how she had to be assisted by two cabinet ministers at the state-of-the-nation address, and also reported that she had rambled on unintelligibly at a cabinet lekgotla, with Social Development Minister Zola Skweyiya finally stepping in to complete her presentation. Although this was denied by her office this week, the denials no longer ring true.

The minister herself told reporters yesterday that she was in good health.

But we all saw it for ourselves - the media, the diplomats, public servants and her cabinet colleagues - all of us witnesses to something bizarre.

Tshabalala-Msimang is clearly a minister in poor health. Given the president's loyalty and reluctance to dismiss those who are ill, perhaps those close to Tshabalala-Msimang should advise her to step down, with whatever dignity she has left.

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Industry opposes smoking curbs

29.01.2007
The tobacco industry is trying to convince Parliament not to adopt more smoking controls at hearings on the Tobacco Products Control Amendment Bill of 2006.

Tobacco kills almost 5-million people every year and this figure is set to double by 2030. Yet this week the tobacco industry will continue its attempts to convince Parliament not to support more stringent measures aimed at curbing smoking.

Bennett Asia of the Department of Health said there was overwhelming evidence that tobacco companies were targeting the developing world. “Already 60 percent of all admissions at Groote Schuur Hospital (in Cape Town) are tobacco-related,” revealed Asia.

He said there was a need to amend the Act as the tobacco industry had exploited several loopholes. “We also need to strengthen the measures available to enforce the Act,” he added.

Asia said the amendments were aimed at increasing fines for those breaking the law, further regulating smoking in public places, banning smoking at homes where there are crèches and other businesses, regulating smoking at entrances to buildings and offices, regulating smoking at outdoor events, barring under eighteens from places where smoking is permitted and regulating manufacturing standards.

Abednego Baker of the National Institute for Occupational Health called for all workplaces and restaurants to be declared 100 percent smoke-free. He quoted from several studies showing there were still high concentrations of nicotine in restaurants and work areas adjacent to smoking areas, despite ventilation systems.

“These (ventilation) systems basically distribute second-hand smoke through a building,” he said.

Baker added that studies in the United States had also shown that statistically there was no significant effect on bar and restaurant revenues once smoking was banned.

Dr Yussuf Saloojee, executive director of the National Council Against Smoking (NCAS), told Parliament’s Health portfolio committee that tobacco was a uniquely dangerous consumer product as it was the only legal product that killed the user when used exactly as the manufacturer intended.

He said that in South Africa tobacco killed one person every 20 minutes or about 30 000 people a year.


NCAS supported several proposed changes including:
· restricting smoking near entrances to public places;
· not allowing smoking in private homes used commercially for childcare or educational purposes;
· assisting employees to safely voice their concerns without fear of repercussions;
· regulating smoking at sports events.

Saloojee also called for the amendments to protect domestic workers in private homes and for smoking to be banned in cars with children.

Francois van der Merwe, Chairman of the Tobacco Institute of South Africa which represents more than 95% of the total legal tobacco industry in this country, said although industry supported regulation, it was concerned that it would be “over-regulated”.

He said over-regulation would allow the illegal trade in tobacco to boom.

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Industry opposes smoking curbs

29.01.2007
The tobacco industry is trying to convince Parliament not to adopt more smoking controls at hearings on the Tobacco Products Control Amendment Bill of 2006.

Tobacco kills almost 5-million people every year and this figure is set to double by 2030. Yet this week the tobacco industry will continue its attempts to convince Parliament not to support more stringent measures aimed at curbing smoking.

Bennett Asia of the Department of Health said there was overwhelming evidence that tobacco companies were targeting the developing world. “Already 60 percent of all admissions at Groote Schuur Hospital (in Cape Town) are tobacco-related,” revealed Asia.

He said there was a need to amend the Act as the tobacco industry had exploited several loopholes. “We also need to strengthen the measures available to enforce the Act,” he added.

Asia said the amendments were aimed at increasing fines for those breaking the law, further regulating smoking in public places, banning smoking at homes where there are crèches and other businesses, regulating smoking at entrances to buildings and offices, regulating smoking at outdoor events, barring under eighteens from places where smoking is permitted and regulating manufacturing standards.

Abednego Baker of the National Institute for Occupational Health called for all workplaces and restaurants to be declared 100 percent smoke-free. He quoted from several studies showing there were still high concentrations of nicotine in restaurants and work areas adjacent to smoking areas, despite ventilation systems.

“These (ventilation) systems basically distribute second-hand smoke through a building,” he said.

Baker added that studies in the United States had also shown that statistically there was no significant effect on bar and restaurant revenues once smoking was banned.

Dr Yussuf Saloojee, executive director of the National Council Against Smoking (NCAS), told Parliament’s Health portfolio committee that tobacco was a uniquely dangerous consumer product as it was the only legal product that killed the user when used exactly as the manufacturer intended.

He said that in South Africa tobacco killed one person every 20 minutes or about 30 000 people a year.


NCAS supported several proposed changes including:
· restricting smoking near entrances to public places;
· not allowing smoking in private homes used commercially for childcare or educational purposes;
· assisting employees to safely voice their concerns without fear of repercussions;
· regulating smoking at sports events.

Saloojee also called for the amendments to protect domestic workers in private homes and for smoking to be banned in cars with children.

Francois van der Merwe, Chairman of the Tobacco Institute of South Africa which represents more than 95% of the total legal tobacco industry in this country, said although industry supported regulation, it was concerned that it would be “over-regulated”.

He said over-regulation would allow the illegal trade in tobacco to boom.

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Doctors, nurses nowhere to be found

January 19 2007
The shortage of health professionals is back in the spotlight, with the South African Medical Association sounding a warning that even in the private health sector, doctors and nurses are hard to come by.

"(The association) is concerned about the increasing difficulty attracting healthcare professionals to work in the public health sector. There is even a lack of doctors and nurses in the private sector," said association head Dr Kgosi Letlape in a challenge to the health minister.

Dr Manto Tshabalala- Msimang has just returned to work after a long illness, and Letlape said yesterday he would get in touch soon with a view to tackling the healthcare challenges of 2007 and beyond.

His comments follow serious concerns raised last month in the SA Medical Journal which said that, without major intervention, rural healthcare delivery capacity would collapse from next year when a change to the rules governing medical student internship would dramatically cut the number of doctors coming into the field. In 2008 students will have to do a two-year internship for the first time.

The Journal estimates that this will mean a 78 percent reduction in the pool of available, sufficiently qualified community service conscripts for that year.

"Just as the situation rights itself the following year, the three-year contracts of hundreds of foreign doctors will come to an end, progressively depleting the 2 250-strong foreign doctor workforce each subsequent year, unless willing new English-competent recruits are found," it said.

Letlape pulled no punches when he said the emigration of doctors was "an old story", and could no longer be blamed entirely for the shortage.

One of the major problems, he said, was the absence of a medical school in four of the nine provinces, which would create career opportunities and increase research capacity, so beginning to tackle the crisis.

Letlape was highly critical of moves to "dismantle" Medunsa and turn it into a satellite campus of Limpopo University.

In the US, he said, there was a medical school for every two million people, and the country still had a shortfall of doctors.

"In Gauteng, we have three medical schools for seven million people and the Medunsa situation is one of the saddest because it's the institution that trains the highest number of black doctors in the country," Letlape said.

The Western Cape has two medical schools, and there are one each in the Free State, KwaZulu-Natal and the Eastern Cape.

According to the Journal, one respected audit five years ago had 23 407 South African-born workers practising a medical profession in Australia, Canada, New Zealand and the US, versus 11 332 doctors and 41 617 nurses working in the public health sector here.

But Letlape warned against perceptions that the crisis was limited to the public health sector: "We are not actually training enough doctors and that is starting to impact on the private sector, too.

"Our population has increased, along with demands for better healthcare, and that requires more doctors than we have.

"We can't keep blaming the fact that doctors leave the country. That's always been the case and what we should be doing is factoring attrition into our forecasts."

Letlape said that to rise to the challenges facing the delivery of healthcare in South Africa, "we need to pool our skills and resources to ensure that patients in both the public and private sector receive the best possible care".

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Don't give Manto new tobacco powers

24 January 2007
Health Minister Manto Tshabalala-Msimang should not be given the "sweeping" powers set out in proposed changes to the tobacco-control law, British American Tobacco (BAT) argued on Wednesday.

David Crow, managing director of BAT South Africa, was speaking on the second day of public hearings on the draft legislation by Parliament's health portfolio committee.

"We're concerned about the sweeping powers that have been [assigned] to the executive," he said. "They're giving the minister extensive powers in lots of areas.

"There are areas that are ill-defined, and what we'd like is more definition [and] a real debate with all the stakeholders."

He said he was hoping for "pragmatic solutions, so we don't get into the problems we've had with previous Acts that have gone through government".

Crow said the existing law was already working extremely well, as witnessed by a reduction in smoking in South Africa, though there was room for improvement.

"Really what we're saying is, let's be pragmatic, let's do it right, let's get all the people round the table, write the legislation properly ... so it can be enforced and workable."

In a written submission to the committee, BAT said the minister already had the power to make regulations regarding "any other matter required ... to achieve the objects of the Act".

Under the new Bill, however, she is to be given powers to make regulations on the location, content, size and format of any sign (such as a point-of-sale sign) required under the Act; on the standards with which a tobacco product should comply; on methods of testing compliance with prescribed standards; and on disclosure of companies' marketing expenditure.

"If the Bill is enacted, material changes to the system of tobacco control could be made without any debate in Parliament," BAT said.

Earlier, the committee heard that smoking should be banned completely in the workplace and all other public places.

An occupational hygienist at the National Institute for Occupational Health, Abednego Baker, told the committee: "I've only got one recommendation: all workplaces should be made 100% smoke free."

He said smoking areas in bars and restaurants were serviced by waiters who were often working there only part-time, and were young and financially vulnerable.

The Bill seeks to give legal protection to employees such as waiters who object to working in smoking areas.

Under the existing legislation, smoking may be allowed only in designated areas that make up only a portion of the total area of the workplace or public place.

Baker said there was "some kind of contradiction" between the tobacco legislation and the Occupational Health and Safety Act, which stipulated that employers had to protect employees from any health hazard in the workplace.

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Tshabalala-Msimang denies being sidelined

January 16, 2007, 17:30

Manto Tshabalala-Msimang, the health minister, has dismissed suggestions that she has been sidelined from government's Aids combating efforts in recent months. She has also challenged her critics to find and present proof that she has in any of her statements on HIV/Aids, said that nutrition must take precedence over treatment.

The minister said the role of nutrition must be understood within the context of the government's comprehensive plan on the pandemic. She said she is still involved in all decision-making.

Tshabalala-Msimang returned to her office today after a three month absence. She was hospitalised for a month last September after she fell ill with a lung infection. The minister said: "I was sick and was not concentrating on what people were saying and obviously people were not going to wait for somebody to get ill before they implement those decisions. Besides the department briefed me on a daily basis on what was happening."

TAC says its prepared to work with minister
Tshabalala-Msimang also denied reports that the Aids plan only gained momentum once she was gone, saying the decisions were taken long before then. The minister said she cannot be held accountable for people twisting her articulation of the comprehensive plan on HIV/Aids.

The Aids plan will be finalised before the South African National Aids Council's first meeting in March. In the past the Treatment Action Campaign (TAC) made no secret of how it felt about the minister's stance on Aids. The TAC said its prepared to work with her as its key objective is to finalise the national strategic plan and if the minister maintains the tone which was set by Phumzile Mlambo-Ngcuka, the deputy president, there should be progress.

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Doctors, nurses nowhere to be found

January 19 2007 at 03:05PM

The shortage of health professionals is back in the spotlight, with the South African Medical Association sounding a warning that even in the private health sector, doctors and nurses are hard to come by.

"(The association) is concerned about the increasing difficulty attracting healthcare professionals to work in the public health sector. There is even a lack of doctors and nurses in the private sector," said association head Dr Kgosi Letlape in a challenge to the health minister.

Dr Manto Tshabalala- Msimang has just returned to work after a long illness, and Letlape said yesterday he would get in touch soon with a view to tackling the healthcare challenges of 2007 and beyond.

His comments follow serious concerns raised last month in the SA Medical Journal which said that, without major intervention, rural healthcare delivery capacity would collapse from next year when a change to the rules governing medical student internship would dramatically cut the number of doctors coming into the field. In 2008 students will have to do a two-year internship for the first time.

The Journal estimates that this will mean a 78 percent reduction in the pool of available, sufficiently qualified community service conscripts for that year.

"Just as the situation rights itself the following year, the three-year contracts of hundreds of foreign doctors will come to an end, progressively depleting the 2 250-strong foreign doctor workforce each subsequent year, unless willing new English-competent recruits are found," it said.

Letlape pulled no punches when he said the emigration of doctors was "an old story", and could no longer be blamed entirely for the shortage.

One of the major problems, he said, was the absence of a medical school in four of the nine provinces, which would create career opportunities and increase research capacity, so beginning to tackle the crisis.

Letlape was highly critical of moves to "dismantle" Medunsa and turn it into a satellite campus of Limpopo University.

In the US, he said, there was a medical school for every two million people, and the country still had a shortfall of doctors.

"In Gauteng, we have three medical schools for seven million people and the Medunsa situation is one of the saddest because it's the institution that trains the highest number of black doctors in the country," Letlape said.

The Western Cape has two medical schools, and there are one each in the Free State, KwaZulu-Natal and the Eastern Cape.

According to the Journal, one respected audit five years ago had 23 407 South African-born workers practising a medical profession in Australia, Canada, New Zealand and the US, versus 11 332 doctors and 41 617 nurses working in the public health sector here.

But Letlape warned against perceptions that the crisis was limited to the public health sector: "We are not actually training enough doctors and that is starting to impact on the private sector, too.

"Our population has increased, along with demands for better healthcare, and that requires more doctors than we have.

"We can't keep blaming the fact that doctors leave the country. That's always been the case and what we should be doing is factoring attrition into our forecasts."

Letlape said that to rise to the challenges facing the delivery of healthcare in South Africa, "we need to pool our skills and resources to ensure that patients in both the public and private sector receive the best possible care".

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Minister Is Sidestepping Teacher-Aids Programme

Government appears to have sidestepped a recommendation to implement a specific HIV/AIDS prevention and treatment programme for teachers and is instead preparing a general "wellness" programme for teachers and pupils.

For years fears have been expressed that SA is losing teachers faster than they can be trained due to HIV/AIDS.

In 2004, the Human Sciences Research Council (HSRC) and the Medical Research Council (MRC) studied the incidence of HIV among teachers and came up with recommendations.

One of these was that the education department and donor agencies "should establish and manage a workplace programme specifically to provide a comprehensive HIV and AIDS prevention and treatment programme".

However, in a reply to a parliamentary question from Democratic Alliance (DA) MP Ryan Coetzee, Health Minister Manto Tshabalala-Msimang said her department was one of the many key stakeholders involved in an initiative which is "the development of a national framework on health and wellness programme for both educators and learners".

This framework is intended to guide the education sector at all levels in the implementation of a wellness programme that "focuses on all health aspects instead of focusing on HIV and AIDS only".

Tshabalala-Msimang did concede that money had been obtained from the US President's Emergency Plan for AIDS Relief for the provision of antiretroviral drugs, particularly for teachers.

DA health spokesman Gareth Morgan said that while the HSRC had highlighted many chronic diseases facing educators, the immediacy of the HIV/AIDS threat deserved an extraordinary response from Tshabalala- Msimang and the national education department.

SA was already facing a critical shortage of educators and had to act swiftly to mitigate the effects of HIV/AIDS on the teaching population, Morgan said.

Specific recommendations were provided in the 2004 survey on educator supply and demand, which the minister had not taken seriously, he said.

Morgan said the health and education ministers "must not hide behind a vague wellness plan for educators" which did not contain the urgency to deal with HIV/AIDS.

"It is clear that the relevant departments need to target educators in need of antiretroviral therapy," he said.

Tshabalala-Msimang said the HSRC/MRC study had found "on the issue of morbidity, that about 12,7% of educators are HIV- positive and 22% of those are in need of antiretroviral therapy".

However, the minister said, HIV/AIDS was not the only factor in teacher morbidity.

Other diseases played significant roles in the health of educators. The most frequently reported of these in the past five years were high blood pressure (15,6%), stomach ulcers (9,1%) and diabetes (4,5%).

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Pressure growing for ousting of Doctor Beetroot

South Africa’s Health Minister Manto Tshabalala-Msimang has had a rough year. In a country where more than 5.5mn people are infected with the Aids virus, any politician charged with managing the pandemic has their task cut out.

But some analysts believe, that 2006 may have been the controversial politician’s last in her post, given that many South Africans, including those with experience of nursing dying relatives, are tired of the saga surrounding her portfolio.

The latest swipe at the Russian-trained doctor came in a newspaper advertisement paid for by Blue Ribbon, a bread and maize manufacturer, and poking fun at her apparent fondness for potatoes, beetroot, garlic and olive oil as Aids cures.

"Tired of people constantly calling for your resignation?," read the advertisement in the Star newspaper which featured a sandwich stacked with the minister’s favourite vegetables and recommending Tshabalala-Msimang eat Blue Ribbon bread to cope with her demanding job.

In her years as health minister since 1999, HIV infection levels have failed to fall significantly and Tshabalala-Msimang has earned a reputation for being stubborn, unapologetic and incredibly uncooperative.

Internationally, the woman known as "Dr No" and "Dr Death" stands as a laughing stock over her penchant for promoting the benefits of vegetable and traditional remedies for those infected with the deadly disease.

Aids activists regularly condemn her actions, including an initial refusal to provide anti-retroviral drugs that prompted a drawn-out court battle. In the end, the minister forced two years ago to make the treatment available to Aids sufferers through the state health system.

International scientists, Aids activists and local opposition politicians - among others - have written her off as incompetent and irresponsible, with some even accusing her of "human rights violations" and "murder." Several months ago, South African Aids activists attending the International Aids Conference in Canada set out to humiliate her publicly by vandalising her health department’s exhibition stand that carried a display of the infamous vegetable cures.

The incident left the government severely embarassed and tongue- tied, but Tshabalala-Msimang has refused to give up her preoccupation with garlic, beetroot, lemon and olive oil concoctions for Aids patients waiting to tap into the health system’s Aids drug supply.

President Thabo Mbeki drew criticism for refusing to act against his minister and sparked debate about whether this meant the two had similar views or whether she was actually just carrying out orders.

Mbeki, who makes available money to fights Aids, is often criticised for rarely mentioning the disease and for questioning the link between the HIV virus and full-blown Aids in 2000.

Calls for her resignation reached their peak recently when Tshabalala-Msimang took ill unexpectedly. During her spell in hospital, two more pragmatic politicians - Deputy President Phumzile Mlambo-Ngcuka and Deputy Health Minister Nozizwe Madlala-Routledge - began talks with the Aids lobby and civil society groups.

The two spoke out against the government’s "denialist" approach to the disease and praised the Aids lobby for their unrelenting stance on treatment, marked a turning point.

Tshabalala-Msimang returned from her illness, guns blazing with denials that she had been sidelined, but the media and health professionals continue to focus what a future without the "Dr Beetroot" might mean for the health of the nation.

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Failing health of public hospitals

MOST of the doctors and nurses interviewed in eight South African public hospitals believe staff shortages and management failures compromise patient care. While professionals are reluctant to acknowledge that this entails avoidable patient deaths, clinicians at one hospital were more forthright: “Everything is done in a rush, and staff are left exhausted. The result is a low quality of care and ... mortality that could have been avoided.”

A nurse in a second hospital commented: “We do not give quality patient care. Now I am alone in the ward, it means I am unable to prevent certain things happening. The result is complications, wound sepsis, longer hospital stays.” This is one among many similar comments from nurses in these hospitals.

It seems clear, on the basis of the eight hospitals studied, that many patients at public hospitals in SA are receiving low-quality health care. Why is this the case? There are three main problems: staff shortages, a dysfunctional relationship between hospitals and provincial health departments, and dysfunctional internal management structures.

All the public hospitals we investigated suffer from acute shortages of staff, particularly nurses and other professionals such as pharmacists and radiographers. Nurses consistently complain of stress, exhaustion and low morale as a result of the heavy workload they have to bear: “We always have to rush: we wash, we medicate, we move on. We cannot have tea, we cannot eat. The pressure leads to absenteeism, as nurses we become demotivated and no longer have empathy. It affects the patients.”

The closure of nursing colleges by government in the mid-1990s is the primary cause of the shortage of skilled nurses. The dramatic reduction in training has not only reduced the supply of skilled nurses, but has also reduced the number of trainee nurses in the wards, so increasing the workload of the trained nurses.

But government has also made other policy decisions that have exacerbated the nursing shortage. It appears that health department authorities, under pressure from the fiscal austerity programme of the later 1990s, significantly reduced the posts for support workers like cleaners, porters, clerks and messengers.

However, the essential role that support staff play in most hospital activities means that this is a false saving, impacting adversely on the utilisation of scarce and expensive professionals such as nurses. For example, the shortage of nursing auxiliaries means that professional nurses have to do more routine tasks; the shortage of porters and messengers means nurses have to collect medicines from the pharmacy or move patients through the hospital; and the shortage of cleaners means that nurses have to clean wards instead of looking after patients. In the wards, managers have to cope with a daily crisis as staff shortages mean shuffling staff from ward to ward, or calling in agency staff, to ensure that at least a bare minimum of service can be rendered. This prevents them from devoting attention to the proper management of health care and resources.

Hospital managers are disempowered and frustrated by the centralised control that departmental officials exert over their everyday activities. Provincial head offices micromanage the hospitals and hedge the hospital managers about with endless regulations and tedious procedures. Hospital managers have little control over budgets, procurement, discipline, staffing levels and staff structures.

Head office officials have very little understanding of the operational complexities of running bigger hospitals, or of the problems faced by health workers in the wards. Head offices frequently make decisions that disrupt or impose failure on hospitals, or worse yet, simply fail to make decisions. The result is that hospital managers cannot be regarded as accountable for health-care failures in the hospitals, as they lack the necessary powers to change things.

Indeed, disempowerment and lack of accountability is rife within the health department bureaucracies, both in head offices and in hospitals. Within hospitals the key problem is dysfunctional management structures. Management is split up into segregated silos according to functions: nurses are managed by matrons and nursing managers, doctors are managed by senior doctors and clinical managers, and support workers are all managed within their own structures. The result is that there is no locus of accountability for the operations of a specific unit of the hospital, a ward, say, or a clinical department.

In the ward the senior nurse is ostensibly accountable for the running of the ward, but in reality she has little control over support staff or doctors. The same applies to a clinical department such as a surgical department: while the clinical head manages the doctors, the nurses, clerks, cleaners and porters are managed by separate supervisors, each in their own silo. This fragmented management structure results in a pervasive disempowerment, frustration and lack of responsibility.

Public hospitals are in a state of decline. All three problems identified here need to be addressed in a comprehensive fashion if decline is to be averted. The National Labour and Economic Development Institute (Naledi) has recommended: the reopening of nursing colleges; significantly increased employment of support workers so professionals, especially nurses, can concentrate on their core tasks; devolving full operational accountability for hospitals to hospital management, leaving head offices to concentrate on strategy, audits and monitoring; and replacing the fragmented silo structures in hospitals with integrated and accountable management structures.

The cabinet accepted these proposals in January this year. Some of them, such as the devolution of management authority, are actually longstanding government policy but have never been implemented. It remains to be seen whether this changes as a result of the cabinet decision.

Critically important, however, will be the allocation of realistic budgets, especially for the employment of additional staff. Finance Minister Trevor Manuel’s revenue overruns and frequent complaints that government is unable to spend its money seem to provide an ideal opportunity.

‖Von Holdt and Murphy are researchers at Naledi and co-contributors to the recently published State of the Nation: South Africa 2007 (HSRC Press). This is an edited version of their chapter. Naledi has been contracted by the Gauteng health department to assist with the implementation of a transformation strategy at Chris Hani Baragwanath Hospital.

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Pharmacy dispensing fee faces another hurdle

A serious disagreement between government and pharmacists over the controversial new dispensing fee legislation is far from over.

Spokesperson for the Pharmacy Stakeholders Forum (PSF) Lorraine Osman on Sunday confirmed they would lodge a court application for postponement of the dispensing fee's implementation later on Monday.

This follows National Health Minister Dr Manto Tshabalala-Msimang's refusal to defer implementation of the new dispensing fee for pharmacists which is scheduled to start next month.

"We're taking the matter to court because we are convinced the proposed new dispensing fee will have a negative impact and wreak havoc on pharmaceutical service delivery in SA," said Osman.

"Implementation of the dispensing fee will place some community pharmacies under crippling financial strain and as many as 75 percent of pharmacies may be at risk of closing."

She said PSF was convinced the fee's introduction would escalate the growing crisis in pharmacies and harm the health of the public as accessibility to medicines will be compromised.

"The minister indicated to the PSF that deferment was also discussed with the Pricing Committee. It seems the Pricing Committee has again failed to comprehend the realities of the present marketplace and the practicalities of providing a comprehensive, quality pharmaceutical service, especially in regard to human resources, return on investment, security and rental costs," she said.

While government is adamant that the new dispensing fee is viable, people in the industry argue it has the potential to ruin numerous small businesses.

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No deal with Manto

Health Minister Manto Tshabalala-Msimang has refused to postpone the date for next year’s implementation of reduced dispensing fees for pharmacists, the Pharmaceutical Stakeholders’ Forum said at the weekend.

“After the close of business on Friday, the Minister of Health informed the Pharmacy Stakeholders’ Forum (PSF) of her decision not to defer the implementation date of the new dispensing fee for pharmacists,” said spokesman Anita Heyl.

A new dispensing fee of R26 was published in the Government Gazette at the beginning of December.
“We met the Director-General of Health on December 5 to inform the department of the potentially negative impact the proposed new dispensing fee would wreak on service delivery in South Africa,” Heyl said.

She added that the fee would place some community pharmacies under crippling financial strain and as many as 75% of pharmacies could close down.

Heyl said that, based on extensive information and the practical experience of its members, the PSF was “convinced that the introduction of the fee will escalate the growing crisis in pharmacies and will harm the health of the public as accessibility to medicines will be compromised.

“The Minister indicated in her letter to the PSF that the matter of deferment was also discussed with the Pricing Committee,” Heyl said.

“It seems the Pricing Committee has again failed to comprehend the realities of the present marketplace and the practicalities of providing a comprehensive quality pharmaceutical service, especially with reference to human resources, return on investment, security and rental costs.”
The current situation has already resulted in closure of pharmacies, Heyl said. Some communities were unfortunately left without adequate pharmaceutical services.

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Deputy seems unscathed after Aids speech

The government's revitalised HIV and Aids message appears to be the real winner, while Deputy Health Minister Nozizwe Madlala-Routledge seems to have emerged unscathed - publicly at least - after outspoken criticism of her boss and the president.

With most of this week's media focus on her reported call for President Thabo Mbeki to take a public HIV test, the deputy minister was able to deflect attention from her other equally candid and arguably more damaging remarks in an interview with the London Sunday Telegraph.

These related to Health Minister Manto Tshabalala-Msimang and Mbeki himself, who, she said, should bear some responsibility for the confusion on the proper way to treat HIV and Aids.

If Madlala-Routledge received a private dressing-down for this and other outspoken views, nobody was saying on Tuesday.

Presidential spokesperson Mukoni Ratshitanga was not aware of any discussion between her and the president, nor was he aware of any intention to have one.

Mabel Dlamini, Madlala-Routledge's spokesperson, did not know of any talks between the deputy and Tshabalala-Msimang.

She also was not aware of any "dressing-down".

Government spokesperson Themba Maseko confirmed on Tuesday that Tshabalala-Msimang was still recuperating at home after being hospitalised in October for three weeks.

Tshabalala-Msimang's spokespersons did not respond to messages, but Maseko said the minister was expected to return to work in the new year.

He could not say whether the minister was in contact with her deputy, who admitted at the weekend that Tshabalala-Msimang had effectively gagged her from speaking on HIV and Aids.

Madlala-Routledge, who along with Deputy President Phumzile Mlambo-Ngcuka, has become the new, less combative face of the government's HIV and Aids policy, put out a statement on Tuesday clarifying the more sensational aspect of her interview, that she had urged Mbeki to take an HIV test.

She acknowledged that while she had not called on Mbeki personally to conduct a public test as claimed, she had replied "yes" to a question on whether people in leadership positions should be tested.

In an indication that she might have come under fire for breaking ranks, Madlala-Routledge said: "I wish to reiterate my commitment to the policy framework as agreed by the cabinet to ensure the whole of government communicate a single, clear and consistent message on HIV and Aids."

It was clear the government has trodden carefully on how to handle the issue, taking two days before a statement was issued.

If Mbeki was seen to publicly take action against Madlala-Routledge, his detractors would have accused him of victimising the deputy minister, who is regarded as a breath of fresh air with Aids activists and NGOs.

It also would have damaged the government's unified message on the pandemic.

However, questions remain on how a junior member of the executive could escape censure, having publicly criticised her superiors all the way to the highest office in the land.

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African minister ends decade of denial on Aids

For two years she laboured in the shadow of her boss, South Africa's notorious health minister, who declared garlic, lemon and beetroot a suitable treatment for the country's victims of Aids.

Now Nozizwe Madlala-Routledge, a plain-speaking 55-year-old Quaker, is being feted as a heroine by health campaigners, Aids sufferers and much of South Africa's media, for daring to end a decade of denial on the disease by the ruling African National Congress.

In the space of a few weeks the deputy health minister has helped turn government policy on its head.

She has publicly admitted for the first time that the government has been in "denial at the very highest level" over Aids.

She is also helping to draw up a five-year plan to triple the number of patients receiving life-saving anti-retroviral drugs and halve the rate of new infections.

Mrs Madlala-Routledge has broken new ground by taking her family with her for an HIV test — and has called on the president, Thabo Mbeki, to do the same.

Fainter-hearted politicians might doubt the wisdom of asking that of a leader who has himself questioned the link between HIV and Aids. But Mrs Madlala-Routledge is confident about calling on her colleagues to follow suit.

"To me it is logical that people in the leadership see the need to do this," she said.

What is more, in an interview with The Sunday Telegraph, she was prepared to criticise those who for years have promoted traditional medicines as an alternative to modern drug treatment, for a disease that claims the lives of 1,000 South Africans every day.

She made clear that her criticisms included both Mr Mbeki and the health minister, Manto Tshabalala-Msimang.

"What has happened in South Africa, which is tragic, is that people are confused about treatment," she said. "I think it was irresponsible of leaders to say people have a choice, because what traditional healers do we know, who know how to treat Aids? I don't know of any.

"In relation to the president himself, he has recently announced a task team on traditional medicine. For me there's nothing wrong with that as long as the task team understands its duty is to assist in research on traditional medicine. But if there is a misunderstanding and they are saying people can use traditional medicine, that is a problem."

Encouraged and aided by her old friend, Phumzile Mlambo-Ngcuka, the deputy president, Mrs Madlala-Routledge has thrown herself into the fray since her immediate boss was sidelined by a lung infection two months ago.

Before that, the health minister's views on Aids treatment had led to South Africa being ridiculed. Mrs Tshabalala-Msimang ensured that her bizarre theories about the benefits of beetroot and garlic were promoted at international conferences.

"It was seen as saying that garlic, beetroot and vegetables can be an alternative to treatment," said Mrs Madlala-Routledge. "It did not reflect government policy, and the government was very, very embarrassed."

She conceded the merits of a nutritionally rich and balanced diet, but added: "I haven't come across any scientific information that tells me particular food items have a special role [in the treatment of Aids]."

Not surprisingly, her uncompromising stance has ruffled feathers at the department of health. Until very recently, she admitted, she had been instructed not to speak on HIV/Aids at all.

"I've been sanctioned because I've spoken in parliament, and was told I may lose my job," she said. "I must only say what she [the health minister] says, and this is official. For me that is gagging. But I've not observed the gag."

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Pharmacist attacks Manto on new fees

A Rondebosch pharmacist, at the end of his tether over new dispensing fees that he says will leave pharmacists insolvent, faces the tough choice of quitting after 16 years.

Rustenburg Pharmacy's Waheed Abdurahman slates Health Minister Manto Tshabalala-Msimang for "demonising" his profession as "rip-off merchants" and "fat cats".

Sham Moodley and Ivan Kotze, co-ordinators of the Pharmacy Stakeholders Forum, met Health Director General Thami Mseleku and members of the Secretariat to the Pricing Committee on Friday, to discuss the potential impact on pharmacists of the new dispensing fee.

The new fee, after years of controversy, was published in the Government Gazette on December 1. They will come into effect in January 2007.

The forum is adamant that the new fees will "precipitate a crisis in pharmacies", impacting on the pharmacists and their employees and also compromise client's access to medicines because pharmacies will be forced to close.

Abdurahman is one pharmacist facing that threat.

Mseleku is expected to return to the Stakeholders Forum by Wednesday with a response to its request for the new fee implementation date to be put on hold.

At the meeting, said Kotze, the forum had pointed out the difference between the pricing committee's theoretical calculation of costs, and the actual costs incurred by pharmacists.

Mseleku has undertaken to present this to Tshabalala-Msimang, who he said would make a decision as soon as possible.

In an open letter to the cabinet, Abdurahman writes that Tshabalala-Msimang is "deliberately destroying the retail pharmacy sector".

He says the department should consult ministers Trevor Manuel and Alec Erwin to arrive at a pricing structure that would keep pharmacies viable.

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Another new medical plan

THE Eastern Cape’s public health system appears set for a major overhaul.

According to a discussion document, the Service Transformation Plan, the “ultimate aim is to reshape the health service delivery system in order to provide accessible quality care health services to all”.

The changes, due to be implemented in phases from March, come a mere six years after a process of rationalisation which saw hospitals across the province such as East London’s Cecilia Makiwane and Frere amalgamated into complexes at significant cost.

The cost of East London Hospital Complex was estimated at R35 million. And it saw its managers occupy rather plush headquarters at the city’s beachfront.

But, then, it was heralded as a move that would see “people-centred quality care to the public”.

Seemingly, though, the Eastern Cape’s health managers and officials have found the amalgamation process to have been undesirable and have now put a new transformation plan on the table.

The major thrust of the new process, according to the report, will be an emphasis on primary healthcare and community health centres, avoiding congestion and oversubscription of services at major hospitals.

This, the document says, is in line with national health policy.

On the face of it, the Health Department has a difficult task ahead in bringing quality care to its clients. It faces massive shortages of skilled personnel such as doctors and nurses.

Earlier this year, national Health Minister Manto Tshabalala-Msimang said, CMH, for example had a 58 percent vacancy rate for doctors. The situation worsens in areas such as the former Transkei.

It appears, though, that the transformation process, is set to become a political football. It has yet to be presented to the Bhisho Legislature and the Premier for approval. The unions have yet to be consulted about a move that will see many of its members relocated to new centres.

There have been efforts to suppress our publication of the proposed changes. Calls have been made to the Daily Dispatch to stop its publication. The Health MEC refused to comment, instead preferring to lash out at our reporters, ranting how she “hates” and “despises” the Dispatch.

The MEC’s feelings aside, it is imperative that one key question is answered: Is it in the interest of the citizens of the Eastern Cape?

If it is, then the plan must go ahead. If it is nothing but a desperate plan to attempt to deal with the hereto unsolved problems of delivery, then it must be scrutinised.

That is the responsibility that Bhisho carries when acting for the people of this province.

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Aids confusion catches up to Manto and Mbeki

Deputy Health Minister Nozizwe Madlala-Routledge has criticised the government's shortcomings in tackling HIV and Aids, saying both President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang must bear some responsibility for confusion over the correct treatment for the virus.

Interviewed for a British newspaper, Madlala-Routledge criticised those who promoted traditional medicines as an alternative to conventional drug treatment.

"What has happened in South Africa, which is sad and tragic... people are confused about treatment... and this has come about because of the confusing messages coming from the very top.

"If I use the example of traditional medicine, I think it was irresponsible of leaders to say people have a choice... because how do those people choose when they don't have the knowledge that is backed up by science?

"It is absolutely irresponsible to say to people who are desperate, who want to live, 'Oh, go to your traditional healer if you want', because what traditional healers do we know of who know how to treat Aids? I don't know of any in my country."

Asked if she included the president and the health minister in her comments, Madlala-Routledge replied "yes".

Expressing concern that high-level decisions were generating confusion, she noted that Mbeki's recent appointment of Professor Herbert Vilakazi as chairperson of a "task team" on traditional medicine might contribute to this, if its role was not clearly defined.

"You see, in relation to the president himself, he has recently announced a task team on traditional medicine and for me there's nothing wrong with that, as long the task team understands its duty is to research or to assist in research on traditional medicine.

"But if there is a (misunderstanding)... that the task team is saying people can use traditional medicine, that is a problem, because what brings about that concern for me is that Vilakazi is chairperson of the task team on traditional medicine and... Vilakazi... is marketing an untested product, Ubhejane, so that's a concern because once people see 'Oh, Professor Vilakazi has now been appointed by the president to be chairperson of this task team and Professor Vilakazi is saying take Ubhejane to cure Aids' - you know what I mean, it's very confusing to ordinary people."

Pressed on whether she was saying it had been a mistake to appoint him, she replied, "Yes, I think so."

The comments are potentially embarrassing for the president, although Madlala-Routledge has a reputation for being outspoken.

The 55-year-old mother of two has become something of a hero to critics of the government's Aids policy and a symbol of the government's new willingness to accept criticism and work with former enemies such as the Treatment Action Campaign through the newly restructured South African National Aids Council.

Along with her old friend, deputy president Phumzile Mlambo-Ngcuka, she has been at the forefront of what has been hailed as the most important shift in the government's approach to tackling the disease in 12 years, with a five-year strategy being drawn up in consultation with civil society organisations, and bold new targets such as the halving of new infections by 2011.

Significantly, it was she, not her boss, who stood alongside the deputy president when the new strategy was unveiled on World Aids Day.

Referring to South Africa's exhibition stand at the Toronto Aids conference in August which featured garlic, lemon, beetroot and African potatoes, but no anti-retroviral drugs - until journalists pointed out the omission - Madlala-Routledge said it had left the government "very, very embarrassed" and did not reflect official policy.

Until very recently she was gagged from speaking on HIV and Aids at all - something she confirmed for the first time in the interview.

"Now I've not been gagged formally. It's not like there's a letter telling me not to talk about HIV and Aids, but I've been sanctioned because I've spoken in parliament and been told I may lose my job.

"I must only say what she says and this is official. For me that is gagging but I've not observed the gag. I've just said what I think ought to be said and nobody has told me to shut up. So I think, I've taken this to mean, what the government has wanted done from the point of view... that there have to be clear and consistent messages. This is what I'm doing, contributing to that."

Madlala-Routledge also commented for the first time on Tshabalala-Msimang's recent outburst on the ANC website, in which she attacked those who portrayed her recent illness as "an opportunity to turn others into champions of a campaign to rid our government of the so-called HIV and Aids denial (sic) at the highest level".

Madlala-Routledge said, "Of course, the minister has indicated her displeasure by writing... a veiled criticism of me, but I haven't had anybody else supporting her from the top."

She said she had not discussed the issue with her boss.

"As you know after her admission to hospital she's been recovering and I've wanted her to concentrate on that. I've not had any discussion with her about it but (I) also felt (I've) not really needed to although I know what I said and I stand by it."

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Health minister missed AIDS Day, but wasn't missed

World AIDS Day has come and gone, but there is still no sign of South Africa's health minister, Dr. Manto Tshabalala-Msimang, who has questioned the link between HIV and AIDS, and suggested that a potion of garlic, beet root and potato can keep the disease at bay.

In August, the contrarian minister, lampooned at home as "Dr. Beet Root," was verbally abused at an AIDS conference in Toronto when she set out the South African booth with vegetables and gave no space to life-saving anti-retroviral drugs, or ARVs.

However, when she entered a hospital to be treated for a lung infection last month, her deputy, Nozizwe Madlala-Routledge -- who previously had been forbidden from making statements on AIDS -- signaled a change in policy, pressing the need for ARVs and describing the Canadian protest as "embarrassing."

Dr. Tshabalala-Msimang is now back at the ministry, but the nation appears to have moved on without her. Last Friday saw huge rallies around South Africa to mark World AIDS Day, but in a change from previous years, government officials participated alongside representatives of the Red Cross and the U.N. program on AIDS, both of which have criticized the slow rate at which ARVs have been made available in South Africa.

Dr. Tshabalala-Msimang's office issued a statement saying the minister played no role in the events because she was still recuperating from her illness. Deputy President Phumzile Mlambo-Ngcuka, who filled in as keynote speaker, announced in the eastern city of Nelspruit that the government planned to cut the rate of new infections in half and that ARVs would be made available to all who need them.

The shift appears to have come from the highest level of government. Sources close to the Cabinet say that after the Toronto conference, President Thabo Mbeki and other ministers were concerned that the matter had gotten "out of hand."

Senior members of the ruling African National Congress have been speaking openly about the damage done to South Africa's image abroad by Dr. Tshabalala-Msimang's backing for alternative medicine.

Global health organizations, including the Red Cross and human rights groups, have argued that, in a country where adult mortality has increased more than 80 percent in the past decade and nearly two-thirds of state-hospital deaths are HIV related, it is irresponsible to promote untested treatments.

Five years of bungled health policies have turned the epidemic into a crisis:

• 5.4 million South Africans are HIV positive.
  
• 950 die from the illness every day.
  
• One-third of women giving birth in state hospitals test positive for HIV.
  

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ARV targets fall short

Global targets to reach universal access to antiretroviral treatment are vague and abstract and will result in the dealth of millions of people, a civil society report warned this week.

The report card is a five country snapshot on the progress of scaling up of treatment. Authored by the International Treatment Preparedness Coalition (ITPC), made up of 800 activists, it says that despite pockets of progress, treatment efforts as a whole is stagnating.

They have urged the World Health Organisation to set a similar target as the “3 by 5” campaign where the global effort was geared towards reaching 3 million people by 2005.

Although acknowledging the worldwide progress in providing treatment to 1.6 million people at the end of June 2006, the report said this success is dwarfed by the 5 million people who may face death if ARV-roll out is not substantially increased.

“A lot of work needs to be done if we are to have universal access. At the moment we don’t have the fastest roll-out and targets needs to be set in order to keep governments accountable,” said Fatima Hassan from the AIDS Law Project and South African representative on ITPC.

The report looks at South Africa, India, Russia, Dominican Republic and Kenya and makes recommendation at country and global levels. ” The Global Fund, PEPFAR and other agencies should put clear systems, lines of accountability and guidelines in place to avoid country-level failures to meet goals associated with their programs.”

Activists said, the report highlights the need for national targets to be informed by global targets. The South African National Strategic Plan on HIV/AIDS came under scrutiny in the report that was criticised for its low targets.

“Even though targets are missed; it creates the incentive for everyone to set up systems and monitor progress. We can hold government accountable when these targets are not reached,” said Hassan. She said the health department cannot use the excuse that high targets will mean lack of quality as the quality of care does not need to drop.

The South African case study found that in October 2006, three years after the South African government agreed to provide ART directly, a combined total of about 265,000 people were on treatment in the public and private sectors. About 165,000 to 175,000 people were accessing ART in the public sector, with some 100,000 to 110,000 receiving it in the private and not-for-profit sectors. But currently 31,000 people are on waiting lists.

“The bottom line is that although we have made progress, a lot of work needs to be done,” said Hassan.

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Aids' Death Certificate Causes a Stir

In the first case of its kind in the country, a South African pathologist has been brought before the Health Professions Council (HPCSA), a national health watchdog, for mentioning AIDS as the cause of death on a medical certificate.

Greer van Zyl, a spokesperson for the HPCSA, confirmed that the next-of-kin of a young woman who died in April 2005 had filed a complaint against former state pathologist Dr Leon Wagner, but said that so far only the formal complaint had been made and the hearing to decide the matter had been postponed.

"The family has charged Wagner with unprofessional conduct after he apparently recorded AIDS as the cause of death without proper evidence or examining the body, as well as for a breach of confidentiality. But, due to the complexity of the case, it has been handed to our Human Rights and Ethics Committee," Van Zyl told IRIN/PlusNews.

In South Africa, medical certificates issued to the family in the event of a death attribute the cause to diseases such as tuberculosis (TB) or pneumonia, without mentioning AIDS, even if AIDS was a contributing factor, to protect the confidentiality of the deceased's status, and the family from stigma.

Van Zyl said, "Objections to the charges have been overturned by the HPCSA disciplinary committee, and the charges against Wagner will remain when the hearing resumes at a date mutually agreed upon by the complainant and the defendant."

Fatima Hassan, of the AIDS Law Project (ALP), a nongovernmental organisation providing legal assistance, agreed that the case was a sensitive one, but was confident that the HPCSA would handle it with the level of attention it deserved.

The issue has sparked debate about the extent to which families might cover up the real reason for the demise of HIV-positive relatives. The opposition Democratic Alliance (DA) party stressed that there was still a large degree of stigma attached to AIDS and the families of HIV-positive people, even though an estimated 5.5 million of South Africa's 45 million population are living with the disease.

According to DA health spokesman Gareth Morgan, "Current policies, which protect the confidentiality of patients at all costs, could actually be hurting the national AIDS awareness campaign. Perhaps by listing AIDS as the cause of death on the certificate we could better monitor the pandemic, as well as eradicate existing stigma and continued denial among both families of patients and the government."

South Africa's approach to the pandemic has often drawn international criticism, usually as a result of Health Minister Manto Tshabalala-Msimang's promotion of natural remedies rather than antiretroviral (ARV) drugs, and the slow pace of the government's ARV rollout.

The first page of a death certificate, which went to the family, only indicated whether someone had died of natural or unnatural causes, while the second page contained more details, such as whether HIV/AIDS or any other factor had contributed to the death, and was used for statistical purposes.

Hassan did not believe statistical reporting on AIDS would improve if doctors listed the disease as a cause of death on both pages. "As it stands, doctors are already required to submit two certificates, one to the family, and another to the government."

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Manto's new dispensing policy slammed

Opposition parties have strongly criticised Health Minister Manto Tshabalala-Msimang for her medicine dispensing fees policy, with the Democratic Alliance calling for the suspension of the new fees system.

"It may take another protracted and expensive legal battle over dispensing fees to convince the Minister of Health that she cannot simply act on her own whims," DA spokesperson Gareth Morgan said on Wednesday.

The Minister should as a matter of urgency suspend the implementation of the new fees she announced recently, and which were due for implementation in January, and meet with the relevant role-players in the pharmacy industry.

"To avoid a legal battle, the Minister at the very least needs to hold discussions directly with pharmacists about these new fees - something that, quite astoundingly, has not happened yet, though the livelihoods of around 2800 pharmacists, and their dependants, are directly affected by these fees," he said.

In September last year, she was ordered by the Constitutional Court to go back to the drawing board after the dispensing fees she had announced were found to be inappropriate.

Now, according to an actuarial study into the implications of the new fees, only around 22 percent of pharmacies were likely to survive, because the fees allowed for an average mark-up of R21.45 an item, whereas pharmacies needed to be able to charge around R28 to cover their overheads.

The implications were particularly dire for rural areas, where the closure of a pharmacy would make medicines inaccessible to many, and the consequences of the loss of thousands of jobs
attached to pharmacies also needed proper consideration.

"The process so far has been one-way communication. The pharmacists have not been able to hold a single meeting with the pricing committee, which is astonishing considering that the committee's mandate was effectively to determine the future of their profession," Morgan said.

Ruth Rabinowitz of the Inkatha Freedom Party said the problems with medicine pricing were entrenched in the White Paper [on health], which made the Minister and her Director General the "Big Sister and Big Brother of health care".

"They decide everything about anything to do with health care and take on the roll of financial techno wizards, although they have no expertise in finance."

They should rather set minimum standards for all health facilities, lay down reasonable minimum packages for medical schemes, set maximum prices only, allowing for bulk discounts in a transparent pricing structure, expose pharmacies to open
competition, and ensure that nobody disobeyed the law.

The virtually arbitrary manipulation of prices up or down for medicines, among other things, had given her the "sticky rope to ensnare health providers in a web of bureaucratic controls that
makes health care provision in our country irrational and uneven", Rabinowitz said.

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Hospitals overwhelmed by dying AIDS patients

Despite government’s introduction of antiretroviral drugs in 2004 to contain HIV in those already infected, thousands of people are still dying of AIDS-related illnesses, and hospitals from Cape Town to Mussina are struggling to deal with the increased load.

Last year, an estimated 320 000 people died of AIDS-related illnesses in South Africa.

Half-a-million people are estimated to be sick enough to need antiretroviral (ARV) drugs but slightly less than half this number is getting ARVs.

The impact of AIDS can be seen on the country’s mortality figures, with a 79% increase in all deaths over the past seven years (1997 to 2004) and a 161% increase in people aged 20 to 49, according to Statistics SA. More people aged between 30 and 34 are dying than in any other age group (58 000 in 2004, in comparison to almost 19 000 seven years before).

“The antiretroviral rollout is not yet at a level where it has significantly altered HIV-related admissions and fatalities at hospitals,”says Professor Helen Schneider of Wits University’s Centre for Health Policy.

In addition, say hospital doctors, people with HIV are only seeking help when they are already very sick and it is difficult to treat them.

“We are overwhelmed by medical patients. We used to admit between 10 and 15 medical patients on a daily basis. Now that number has gone up to 40 to 50 patients per day. And most of these patients have HIV-related complications,” says Dr George Abraham, acting senior clinical manager of Natalspruit Hospital.

The day before Health-e visited Natalspruit, seven people had died in the 734-bed hospital of AIDS-related illnesses.

Up to 60% of all patients in paediatric and adult medical wards countrywide have HIV-related conditions, according to researchers.

But hospitals in areas with high HIV rates are taking even more strain:

• 90% of children and 80% of adult medical patients at Stanger Hospital on KwaZulu-Natal’s north coast are HIV positive, and 30% of male medical patients die.
  
• Three-quarters of the male patients and 70% of female patients who died in the medical ward of Mseleni Hospital in far northern KZN over the past three months suffered from AIDS-related illnesses.
  
• About three-quarters of the patients in the 135 medical beds at Durban’s Addington Hospital have HIV-related illnesses.
  
• Two-thirds of patients tested for HIV at Rustenburg Provincial Hospital in the heart of North West’s mining area, were positive.
  
• Between three and four women die every day in GF Jooste’s medical ward in Mitchells Plain while almost 50 000 medical patients, mostly HIV-positive, were seen in the hospital’s casualty ward last year, almost 20 000 more than in 2003.
  

“It does overwhelm us because really, the AIDS patients are sick,” explains Nombulelo Mabhija, sister in charge of Natalspruit’s 38-bed male medical ward.

“They need to be cared for all the time. They are totally dependent upon us because most of them can hardly walk. They can hardly feed themselves. They can hardly wash themselves, so we have to wash them.”

The Hospice Palliative Care Association (HPCA) last year took care of 35 000 HIV positive people – a mere 12% of those who died.

“We talk about thousands of AIDS-related deaths, but what about the suffering that led up to those deaths? No one talks about that,” says Dr Liz Gwyther, chairperson of HPCA.

“When a person is dying, their physical and medical needs actually increase because of the increased pain management needed.”

A wide range of organisations, including the Treatment Action Campaign and the HIV Clinicians’ Society, have criticised government for not providing ARV treatment at a faster pace.

Meanwhile, UCT Economics Professor Nicoli Nattrass says that a shortage of health staff is a severe problem constraining ARV provision.

“Unless public sector recruitment can keep pace, human resources will constrain the rollout. Addressing the human resources crisis in the public health sector thus ought to be an important priority for the Health Minister,” says Natrass.

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