Removing Motsoaledi will not end the health crisis

While the removal of former president Jacob Zuma was clearly a critical and necessary step in the fight against corruption in South Africa, it is not clear whether the removal of Health Minister Aaron Motsoaledi would help or hinder efforts to bring an end to the crisis plaguing much of our public healthcare system. Indeed, the surrounding politics and entrenched patronage networks are such that no miracles or quick turn-arounds can be expected, irrespective of who is the minister.

That there are very serious problems in South Africa’s public healthcare system is now widely acknowledged. Last week’s Office of Health Standards Compliance (OHSC) report provided evidence of system-wide dysfunction – the Life Esidimeni tragedy and the collapse of oncology services in KwaZulu-Natal provided more concrete examples of what this dysfunction means in the lives of people dependent on the system. In line with reports we’ve been receiving of collapsing morale, some healthcare workers have recently been striking in ways that show no regard for the lives of patients. In other places, over-worked and committed healthcare workers are struggling to keep under-staffed hospitals and clinics above water. Whether you call this a crisis, or a collapse hardly matters. It is clear that some intervention is desperately needed.

The knee-jerk reaction from some quarters have been to call for the head of Motsoaledi. Yet, while the removal of Motsoaledi will appease some, especially those looking to score political points before the 2019 elections, it is by no means clear that it will make things better rather than worse.

A first obvious question is who one would replace him with. Unlike with Zuma, there is no Cyril Ramaphosa waiting in the wings. In fact, most of the MECs for health or other well-connected people with some health experience would clearly be a step down. We need only think back to the disastrous period under Manto Tshabalala-Msimang and the rather rudderless time under Nkosazana Dlamini Zuma, to realise that, even as depressing as things are now, it could get much worse.

That Motsoaledi is a much better health minister than his predecessors might be damning with faint praise, but in some respects at least he has been remarkably successful in more objective terms. The massive growth of our HIV treatment programme is so often mentioned that we’ve become somewhat dulled to it, but it truly is a magnificent achievement. Hundreds of thousands of people alive today, would not be alive had it not been for the programme. Under Motsoaledi’s watch South Africa has also been faster than any other high TB burden country in making new tests and treatments available. We easily take this for granted, but there can be little doubt that your prospects are generally better if you have drug-resistant TB in South Africa, than in say India, Russia or China.

It is also notable that some of the strongest evidence currently being used against Motsoaledi has been generated by a body he helped set up. That the OHSC has been established and is functioning reasonably well, much better than say the office of the Public Protector, is partly Motsoaledi’s doing and will be an important part of his legacy.

Yet, despite Motsoaledi’s various successes, it is undeniable that he has been powerless to shield the healthcare sector from the wider decline of our public service in the Zuma years. In this respect he has failed, although some might argue that he played a losing hand about as well as one could have hoped.

As we found in our recent Health4Sale investigative series, provincial departments of health such as those in North West and the Free State have been stripped of most of their competent and principled staff so as to facilitate the looting that is occurring there. The extent to which professional, lawful management of these departments has collapsed is still not widely understood or appreciated outside of the healthcare sector.

Could Motsoaledi have done more to stop the rot in the Zuma years? It seems likely that he would have been reshuffled had he thrown his weight around more and thus decided to rather do what he could from within the system. That is a strategic decision one could quite reasonably agree or disagree with. Either way, since the change in government earlier this year Motsoaledi has been outspoken, certainly regarding North West, in a way he never was before. It is also to his credit that he was one of the most outspoken leaders in the ANC in the critical period when Zuma’s fate was decided. As with many other problems in this country, I suspect he understood that the removal of Zuma was also a critical first step toward the revival and rehabilitation of the public healthcare system.

While some attempts are being made to turn the situation around in North West, the battle to restore provincial health departments into decent shape and to instil an ethos of service and professionalism will take years. Many of those who are corrupt, or who have facilitated corruption, are still in their positions – and even under Ramaphosa’s “new dawn” the vast majority of the politically connected are still untouchable. Can, will, Motsoaledi help to reform these dysfunctional provincial departments? Will he be willing to spend political capital to take on underperforming MECs and heads of departments in the Free State, Mpumalanga and Limpopo, or will he have limited himself to weaker, already compromised provinces like North West?

While some are calling for Motsoaledi’s head, at the other end of the spectrum there are calls to give the minister of health greater powers over provinces. While one understands the impulse to take over and manage that which is being mismanaged, the national department doesn’t have even nearly the capacity required to micromanage the entire system. In addition, while the impulse to centralise is understandable in the current context, it goes against most of what we know about how best to manage healthcare systems. In addition, centralisation could back-fire horribly if the next health minister turns out to be another Tshabalala-Msimang.

One thing that hasn’t changed since Ramaphosa became president is that the ANC’s internal politics is still the sand in the gears of much of government. Had the ANC deployed and appointed according to skill and commitment, there would be no impulse to centralise. But as we know all too well, MECs, heads of departments, even directors are political appointments made mostly for party-political reasons.

It is clear that the practice of cadre deployment must stop if we are to have any success in bringing an end to our public health crisis. In conjunction with a professionalisation of provincial health departments we will require a serious and ongoing anti-corruption campaign. These solutions will require sustained political will over a period of time – both inside and outside of the healthcare system. They are not quick fixes.

Apart from the human resource consequences of the Zuma years, there is of course also the broader financial toll the years of corruption and mismanagement have taken. In health care this has meant shrinking budgets at a time when services should be expanding. Provinces both have less money and less capacity to spend it wisely. This financial hole is another deep-seeded problem that we have no quick fix for.

Yet, even though there are no quick fixes, there are some immediate moves that can start changing the mood and set us on the right course. While the minister’s position can be debated, there are others who should clearly be fired right away. One is David Motau, who has overseen the recent decline in the Free State’s healthcare system and who signed off on various dodgy contracts in his capacity as head of department of the Free State Department of Health, such as those awarded to Regenesis Biotechnologies and Buthelezi EMS. Another is Butana Komphela, the Free State MEC for health, who has done very little to fix the health system in his province and who should go for similar reasons to Motau. Limpopo Health MEC Phophi Ramathuba should answer for the use of the controversial Buthelezi helicopter ambulance service in that province and for her mishandling of the Ndlovu affair.

MEC Sibongiseni Dhlomo should be held accountable for the oncology crisis in Kwazulu-Natal. Whereas some should be fired since they are not up to the job, others should be investigated and then prosecuted, and if not prosecuted, then at least not recycled and given cushy positions in Parliament. How serious can the ruling party be about corruption if it fails to act against the deeply implicated former Gauteng MEC for health Brian Hlongwa or former Free State Health MEC Benny Malakoane?

During the Health4Sale investigations a long-serving public servant shared with us the theory that at any point 10% of people are fully principled and will insist on doing the right thing while 10% will steal if given the opportunity. The middle 80% are on the fence and go along with the prevailing atmosphere of the day. The prevailing atmosphere in many provinces is one of congenial looting and absolute indifference to the consequences of that looting. The job ahead of us, and ahead of government, is to change this prevailing atmosphere. As discussed above, we do that through locking up corrupt people, holding underperforming people accountable and by ensuring we entrust our provincial health departments only to committed and qualified people.

In addition, it may well be that, given the years of crisis and mismanagement that we have behind us, some symbolic renewal and some new blood is also now needed. A credible and serious new minister of health that comes in, say after next year’s elections, with a strong mandate to end corruption in the healthcare system and that has the full backing of her or his political party could send a strong signal that might help revive morale in the system.

But right now, no new minister would have the full backing of the ANC and no new health minister would make untouchable MECs and premiers suddenly touchable. If the president were to appoint a new health minister tomorrow, that person will face the same set of hard-to-solve problems as Motsoaledi and be similarly powerless to turn around failing provinces. The risk, of course, is that such a new minister would have less political clout, less passion for the health of the people, less sense on policy issues, and might be corrupt. That is probably not a risk worth taking. DM

Low is co-editor of the public health magazine Spotlight (www.SpotlightNSP.co.za). He was previously the Head of Policy of the Treatment Action Campaign. The views expressed in this article are his own.