Assessing Dr Zweli Mkhize’s time as health minister: What we can learn about health and good governance

It came as something of a surprise when Mkhize was appointed minister of health in May 2019. As one of the ANC’s top six, who was also thought to have presidential ambitions, we thought it unlikely he would settle for the health portfolio – which in those pre-Covid times wasn’t quite the high-profile position it is now.

On the positive side, the appointment of someone as senior as Mkhize signalled that health was being given high priority in the new administration. Having more political clout than his predecessor, Dr Aaron Motsoaledi, in theory meant Mkhize would have a better chance of bringing much-needed reforms to provincial healthcare systems. We were also cautiously hopeful that Mkhize’s firmer hand would help better organise and direct the National Health Department and the various national health entities than was the case under Motsoaledi. Clearly an intelligent man with some political chops, we thought he might be able to get things done.

But we also had our doubts. 

When an unsafe circumcision device was purchased and used by the KwaZulu-Natal health department in 2010 when he was premier of that province, he was dismissive of people’s concerns – both about the potential harm to young men and possible irregularities in the procurement of the device. Indeed, there was no shortage of tender controversies in KZN in the years Mkhize was premier. But neither was there any clear evidence, at least not that we are aware of, that he himself was corrupt.

On balance, we were cautiously optimistic that Mkhize might be able to address some of the chronic health governance issues that have plagued our healthcare system over the past two decades.

Two years down the line, and with President Cyril Ramaphosa having announced Mkhize’s resignation on Thursday night, it is clear that our optimism was misplaced. Mkhize was first placed on special leave eight weeks ago following shocking revelations about a communications contract awarded to some of his close allies and reports that his family received what amounts to kickbacks. The Special Investigating Unit (SIU) investigated the matter – and once they submitted their report to the President the writing was on the wall.

A grubby corruption scandal

There is, of course, a story to be told about what Mkhize did and did not achieve over the past two years, but to some extent nuance will inevitably be lost in the shadow of the grubby corruption scandal that brought about his downfall. Wherever the legal process goes after the SIU’s report, Mkhize was either actively corrupt or unable to prevent corruption being perpetrated right under his nose – both good reasons he should never again hold public office.

In the first place then, Mkhize will be remembered as a minister who lost his job because of a particularly grubby corruption scandal. 

In an extra twist in the tale, the Digital Vibes scandal in the end made Mkhize toxic to the very project he was originally brought in for: implementing National Health Insurance. Even with Mkhize gone, the ANC will have a hard time convincing the public that we will not see more such looting once the NHI is implemented. There has, after all, been little willingness from ANC members in Parliament to engage seriously with people’s concerns about the proposed NHI structure and governance arrangements set out in the NHI Bill.

Perhaps this is the most valuable takeaway of the Digital Vibes saga for the country’s NHI plans – a clear warning of what can happen when the buffer between politics and administrative governance is erased to centre power in one person.

A very tough job

But, of course, Mkhize was also the minister who, more than anyone bar the President, had the responsibility to respond to the Covid-19 pandemic in South Africa. The pressure on him in this regard was immense. Decisions often had to be made quickly and based on very limited information and with life-and-death consequences.

Often the impression one got of him on those many late-night media conferences, was of someone who was working very hard and who was, in his way, deeply committed to saving lives and protecting people from Covid-19. And yet, we have to square that image of him with the grubby details of Covid-19 funds being misdirected to help pay for his daughter-in-law’s hairdressing salon. Maybe acknowledging this dissonance, rather than writing people off as all good or all bad, brings one closer to understanding why these types of situations keep arising.

On the positive side, Mkhize clearly understands the science of Covid-19 and generally stuck to it. There was never any question of the kind of anti-scientific nonsense we saw under former health minister Dr Manto Tshabalala-Msimang. Even though transparency was patchy on his watch, he did host media briefings and he did answer questions from the media, although his overly controlling management style and the selective release of information certainly counted against him.

As to how well he did in the Covid-19 response, there will be differing opinions. 

Take vaccine procurement. The market for vaccines has been and remains extremely competitive. There is nothing set in stone about the volumes we have procured. We could have done both better and worse depending on when and how we negotiated and what we were willing to pay. One view is that both Mkhize and Ramaphosa dropped the ball by not personally getting involved in high-level negotiations at a much earlier stage. Seen in this light, the fact that we went into a third wave with only a small percentage of the population vaccinated is a governance disaster – some might even argue it is worse than the Digital Vibes scandal. On the other hand, some may argue the government deserves credit for procuring two of the best available vaccines and scaling up provision rapidly, even if we started late.

Similarly, there were, and still are, differing views on the decision not to use the AstraZeneca vaccine, of which we had a million doses in the country back in February. Depending on how you read that situation, South Africa was either dealt a bad hand and had no choice but to let the vaccines go, or was dealt a so-so hand and played it very badly. 

Control, but at what cost?

This brings us to the niggly issue of who Mkhize chose as his advisers and what we meant earlier by his controlling management style – issues that no doubt affected his decision-making on the key Covid-19 questions.

Backtrack a moment to May 2020, when Deputy Director-General in the Department of Health Dr Anban Pillay, presumably with Mkhize’s blessing, wrote to the South African Medical Research Council, essentially to try to get Professor Glenda Gray fired. To disagree with Gray was obviously fine, but to try to get her fired was thuggish. It sent a strong message that if you wanted to be in the inner circle, you had to toe the line. It thus came as little surprise when some of the more outspoken scientists were essentially purged from the Ministerial Advisory Committee.

This controlling mindset was also evident in the National Department of Health. Though the President appoints directors-general, Mkhize was granted his wish when Dr Sandile Buthelezi was given the job. Buthelezi, among others, showed his loyalty a decade earlier when he joined Mkhize in defending the use of the aforementioned unsafe circumcision device in KZN. While Buthelezi deserved to be given a fair chance once appointed, the fact of his appointment signalled that Mkhize’s top priority was to surround himself with trusted allies and secure power in the department. 

The impression we have, admittedly mostly from the outside, is that very little has improved at the department over the past two years – there are some competent people, but in general the department seems to be undercapacitated, eternally in firefighting mode, and perhaps most concerningly, poorly managed. This is clear from the procurement and contract management disaster that is the Digital Vibes scandal and our relatively slow vaccine procurement, but also from the rudderless response to the health system’s human resource challenges (despite a new strategy that we suspect is rapidly gathering dust), failing to expeditiously address issues with private-sector regulation identified by the Competition Commission’s Health Market Inquiry, and the mind-boggling delay in releasing a critically important tuberculosis survey – eventually released about a year after it was ready for publication.

Firm leadership may, under certain conditions, help rehabilitate an organisation, which is what we hoped would happen when Mkhize became health minister. Yet, it seems an obsession with control had the opposite effect and ended up further paralysing a department that already was not functioning optimally.

The past two years may thus also serve as a reminder that, to build a more capable state, we must maintain a clear distinction between the roles of ministers and directors-general (politics and administration) – and when recruiting the latter, we should prioritise professionalism and management skills and forget about political loyalties. We should also, for good, let go of the illusion that centralising power in a minister, as is envisaged in the current NHI Bill, for example, offers any shortcuts to greater efficiency or professionalism. 

It clearly doesn’t. DM/MC

Marcus Low is the Editor of Spotlight.

* This article was produced by Spotlight – health journalism in the public interest.