‘NHI is his hammer’ – Mixed feelings as Aaron Motsoaledi returns to the health ministry

2 Jul 2024

While some members of South Africa’s medical fraternity and civil society advocates were cautiously optimistic about the return of Dr Aaron Motsoaledi as Minister of Health, some critics have pointed out that he had, after a 10-year stint in the position, left the public service in a worse state than he found it. He now returns to a department on its knees.

The problem with the resurrected Minister of Health, Dr Aaron Motsoaledi, is that if you only have a hammer, every problem looks like a nail. This is the view of Dr Aslam Dasoo from the Progressive Health Forum. He fears Motsoaledi’s hammer is the National Health Insurance (NHI).

Motsoaledi is a medical doctor who held two terms as Minister of Health in former president Jacob Zuma’s Cabinet before being shuffled to Home Affairs. On Sunday, President Cyril Ramaphosa announced that he would return as the Minister of Health in the country’s 7th administration.

Former health minister, Dr Joe Phaahla, has been demoted to deputy minister.

Dasoo said that under Motsoaledi’s watch, the country saw the biggest decline in access to health services across the board, as well as the biggest degradation in health services.

“This means that now the technically most proficient cohort in the public service, health professionals working in the state hospitals, are on their knees. It is an incredible indictment on this government that it cannot see that this moment presented an opportunity for a reset or a step change,” he said.

Dasoo said while they took note that Ramaphosa had to try to accommodate all factions within the ANC, it was a terrible indictment that he could not find someone else for the post.

“The sector is on its knees,” Dasoo said. “It beggars belief and boggles the mind.”

He said that as health was mainly a provincial competency, the provinces were where the rubber met the road.

“Gauteng is the worst poster child for this,” he said.

He said the NHI was not the answer to fix incompetent provincial health departments.

Dasoo said Motsoaeledi presented the first unworkable NHI proposition and also failed to deal with the findings of Justice Sandile Ngcobo’s inquiry into private healthcare in the country, instead focusing on “gathering money” through the NHI.

“We will not be silent,” he said.

“They must not expect to have a free run here. People’s lives are lost because of their ineptitude and their negligence,” Dasoo added.

Read more in Daily Maverick: Assessing the Motsoaledi years

The Life Esidimeni tragedy also happened on his watch as minister. In 2017, Motsoaledi said in a speech: “Needless to say, we are deeply distressed and angered by the death of mentally ill patients that were transferred from Life Esidimeni mental health facility in Gauteng.

“This constitutes one of the periods of darkness in the history of our country, but dare I say, it was also a moment of madness in the provincial health department.”

Past achievements

However, Motsoaledi is also the minister under whose leadership the biggest cohort of patients in history was initiated on antiretrovirals. And he was the minister who created the post of health ombudsman.

Russell Rensburg from the Rural Health Advocacy Project said Motsoaledi’s record in expanding coverage for HIV, TB and maternal health spoke for itself.

“Under his tenure, we also saw the implementation of the Occupation Specific Dispensation, increasing salaries for healthcare workers. We look forward to working on how, under his current tenure, we can strengthen district health services.

“We think the minister should have three major priorities. First, we need to focus on strengthening the national Department of Health’s capacity to lead on a coordinated plan to strengthen the governance of the national health service.

“Second, he will need to support the implementation of the National Health Insurance Act, the establishment of the NHI Fund and the appointment of the board. Additionally, he will be setting up several ministerial advisory boards.

“Last, he will need to begin the process of implementing the reforms of the private health sector as recommended by the Health Market Inquiry,” Rensburg said.

The General Secretary of the Treatment Action Campaign, Anele Yawa, said the Cabinet was too bloated, but that given Motsoaledi’s previous efforts to get most people living with HIV on to treatment – and his leadership role in crafting the beginning stages of the NHI – they were willing to work with him.

Yawa called on the country’s health MECs to work together to fix the failing clinics in the provinces.

It was under Motsoaledi’s political leadership that the first 10 districts were announced for NHI pilot projects in 2009. At the time, there was an optimistic view that the scheme would be “phased in” from 1 April 2012.

Read more in Daily Maverick: National Health Insurance: It’s not just about the money

Blame game

During his previous stint as health minister, Motsoaledi also announced a 10-point turnaround plan for health in the country, but failed to deliver on even one of them, said HIV clinician and Wits professor Francois Venter. He pointed out that this was similar to what had happened under Motsoaledi at Home Affairs.

Read more in Daily Maverick: Minister Motsoaledi apologises to South Africa for ‘the mess created’ by his department

He also said that, in the past, Motsoaledi had blamed foreigners for overcrowding hospitals and causing health services to fail.

In a 2019 statement following Motsoaledi’s claims, Amnesty International said: “Minister Motsoaledi should stop this shameless scapegoating of refugees and migrants. He has been in charge of the health department for almost a decade and should have been fully aware of the challenges faced by the public health system, including the need for more investment, to address the health needs of the growing population. He has failed to take adequate action.”

Motsoaledi launched a similar attack against the Helen Suzman Foundation during a court case that successfully overturned his decision to end Zimbabwe Exemption Permits.

In an opinion piece, the late immigration lawyer Gary Eisenberg described Motsoaledi’s “crusade” against immigrants as contrary to human rights.

Poor-quality healthcare

In a 2018 press conference, Motsoaledi addressed claims that the NHI couldn’t be implemented while the quality of healthcare remained poor.

“We are painfully aware of the fact that some people believe that even before we open our mouths about NHI, we must sit and fix the ailing public healthcare system first,” he said.

“We are very much alive to the problems of poor quality and lack of efficiency in the public healthcare system. That is not a matter of debate.

“The National Development Plan (NDP) has actually flagged it unambiguously. It said in implementing NHI, South Africa has two problems to solve: the existing cost of private healthcare, and the poor quality of care in the public health system.

“Clearly, the NDP regards these two as the terrible twins of the healthcare system. Hence, they need to be tackled simultaneously. If we do them one after the other, it means we are planning to take the next half a century before we talk about NHI. That is undesirable.

“Fixing the quality of public healthcare is never going to be an ending event. It is rather an ongoing and continuing process which has no end as long as the health system exists among people.”

There doesn’t appear to be a lot of hope that the quality of healthcare in SA is going to substantially improve.

The South African Medical Association (Sama) said in reaction to Ramaphosa’s announcement that they were disheartened by the expansion of the Cabinet.

Sama chairperson Dr Mvuyisi Mzukwa said it was a “missed opportunity to reallocate crucial funds to our struggling healthcare system”.

“Our nation faces significant health challenges that require immediate and substantial investment, and this expanded Cabinet diverts essential resources away from where they are needed most.”

He said they were not focused on the “personalities of those appointed to the health portfolio”.

Mzukwa added: “We are committed to working with those appointed in the health ministry to address the pressing needs within our healthcare system. Our primary concern remains the health and wellbeing of all South Africans, and we will continue to advocate for measures that improve service delivery and health outcomes.”

He emphasised that a more efficient Cabinet could have freed substantial financial resources desperately needed to improve healthcare infrastructure, recruit and retain medical personnel – some of whom remained unemployed – and invest in preventive care initiatives. DM

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South Africa

Past achievements

Blame game

Poor-quality healthcare