Not many ministers, public servants or government officials occupy their offices in Parliament’s 120 Plein Street building around 6.30am, almost every day. But on the fourth floor things are usually happening around this time.
Renowned for her long working hours, health minister Dr Manto Tshabalala-Msimang arrives amid the early morning hustle and bustle created by her support staff ready to face another day at the helm of a department that has been under constant fire for it’s perceived unwillingness to address the hot potato of preventing mother to child transmission (MTCT) of HIV.
Not only has her department been severely criticised, but she has personally, as the health minister, also come in for her fair bit of opposition ‘ being accused of stalling on the issue of preventing mother to child transmission, not being interested in doing anything about the epidemic and being a “yes man” for President Mbeki, among others.
But those who work with her are convinced that she is on the right track, passionate about solving the myriad of health problems in this country and committed to expanding the MTCT pilot sites, but not prepared to surge ahead only for the programme to fall flat after a few months.
Those who oppose her are quick to admit that they would not like to be in her shoes, tasked with finding solutions to an epidemic that is estimated to have infected almost five million South Africans and set to orphan in excess of one million children in the next few years. And all this while being faced establishing a sustainable primary health care system ‘ the basis on which the MTCT programme will be built.
When questioned around the perceptions and reports in the media, Tshabalala-Msimang remains firm that she will move ahead when the time is right. She does not seem overly concerned that perhaps the media and others are not sending out a message she is trying to convey – that at the end of the day the buck stops with government . “When I go to my constituency (Kwa-Zulu/Natal) and I speak to them, they understand where we are coming from.
“We are all at war with each other over 15% of the babies born each day to HIV positive women,” says Tshabalala-Msimang. (30% of HIV positive pregnant women transmit the HI-virus to their babies during birth. Drugs such as nevirapine halve this figure)
“It is important to sustain the programme and not just give the woman a tablet and forget about her”.
Before launching the MTCT pilot sites, the health department drew up a protocol that has been described in WHO and UNAIDS circles as the best they’ve seen when dealing with his issue.
The protocol addresses issues such as managing the delivery and pregnancy to limit transmission, training of health workers on issues such as rupturing the membrane, nutrition, the management of opportunistic infection, breastfeeding and the use of invasive instruments.
“So, we had to put these protocols in place and health workers needed to be trained in accordance with these guidelines. This took and still takes time – it is not an easy exercise,” Tshabalala-Msimang says.
According to Tshabalala-Msimang they had also not calculated that they would need extra rooms at the sites to offer confidential counseling, clearly a huge hurdle in most of the provinces.
According to research at least half of the pilot sites do not have space to counsel the women. “For example in the Free State they had to get containers and they have calculated the cost of doing this across the province, a huge cost implication.”
“Sometimes women are counseled under trees. Now when we talk about our renewed commitment to offer people quality care, this is an example of shabby care. Good counseling takes at least an hour and it needs to be confidential.”
Tshabalala-Msimang added that the feeding aspect remained a complex issue. “We are having problems. There is so much pressure on women who receive the formula feed to breastfeed. So, they end up breastfeeding or mix feeding. Maybe we are asking too much of the women, expecting of them to change their behavior so drastically.”
She points out that exclusive breastfeeding meant that the mother was also barred from giving the infant any fluid including water, gripe water or cough syrup.
The department was also negotiating with nevirapine’s manufacturer Boehringer Ingelheim to produce the syrup for the newborns in smaller doses. “At the moment it comes in huge bottles so it is impossible to send a dose with the woman causing many, who don’t get to the clinic in time when they are in labour to lose out,” Tshabalala-Msimang explains. The woman is giving a tablet to take home when receiving antenatal care.
“I can’t just say today ‘ We’re rolling out across the country. We don’t have the capacity or facilities. We’re just not there.”
But Tshabalala-Msimang hinted that those who had the capacity or facilities to offer this service would go ahead and expand. “The director-general (Dr Ayanda Ntsaluba) is interacting with each provincial head of department to talk about the problems at each individual site and to find ways to overcome these hurdles.”
She also indicated that the head of HIV/AIDS Dr Nono Simelela would be visiting the individual sites, a clear commitment towards overcoming any barriers.
“There is no use in just rolling out and it all falls flat at the end of the day with marches in the streets again,” she said, clearly referring to the Treatment Action Campaign, who has been targeting government policy using among other techniques, sit-ins, pickets, marches and more recently, the court.
“There is not a single province that can roll out. Yes, there are pockets in some provinces that are in a position to expand,” Tshabalala-Msimang adds.
“We also need to follow the infants until they are 12 months old, the eldest one is now eight months.”
Tshabalala-Msimang said claims by the Western Cape that they had such data (infection rates of 12 month old infants) were unsubstantiated. “Fareed Abdullah (head of Aids in the Western Cape) is yet to give me such data.”
She points out that there is not a single country where every pregnant woman has access to nevirapine.
“We are talking about this nation, not Zambia or another nation. This nation. And we need to base our decisions on the needs of this nation.”
Tshabalala-Msimang said she was keen to launch a huge campaign around food gardens that would in turn improve the nutritional status of all South Africans, but especially those living with HIV/AIDS.
“When I was young, we had to go to the river every morning to fetch water for the vegetable garden. My mom made sure that we always had carrots, spinach’¦
“People need to change their behaviour, they need to take responsibility for their health and sexual behaviour. They can’t say that this is now a democratic government sit back and wait for government to do everything for them. They must take some responsibility.”
On the issue of water and sanitation, Tshabalala-Msimang said the cholera epidemic had been “a kick in the butt”.
“We did lag behind when it came to sanitation, but we now seem to be on track.”
She said she was also keen to investigate the possibility of communities erecting water tanks to catch the rain in areas such as KwaZulu-Natal with high rainfall figures.
“But you know we have so many competing demands in the health sector. We were halfway with building and renovating clinics when we realised it was of no use unless we addressed issue of quality of care.
“So, now we are looking at setting up health posts in some areas. Every district should have a health centre with health posts.”
Tshabalala-Msimang said she had also launched a primary health care package that every facility needed to implement.
“But there are still areas with inadequate access.”
Tshabalala-Msimang said the renovation of hospitals was going ahead, but that they had added to that the need to change the management at these facilities and buy equipment to their priorities.
“We are dealing with huge and enormous backlogs, but we are putting in a lot of effort to improve our hospitals.”
Tshabalala-Msimang indicated that she would be applying for money from the United Nations Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria “We have not received the format on how to access these funds, but I think we have a very good chance of accessing funds for tuberculosis.
“We have a huge problem with TB, but it can be cured.”
One can’t help wondering whether this minister secretly wishes that she could say for HIV/AIDS – Chances are a cure for HIV/AIDS or at the very least a vaccine would top her wish list.