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Yogan Pillay, South African healthcare’s insider outsider

Yogan Pillay, South African healthcare’s insider outsider
One of the awards Pillay received over the years was from the KNCV Tuberculosis Foundation for his work in combatting TB. (Photo: Supplied / Bhekisisa)
Sean Christie
By Sean Christie
13 Jan 2025
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Yogan Pillay has worked under every health minister since 1994, making him the ultimate healthcare insider. Now he’s an outsider, but one with tremendous influence. Sean Christie visited him at home in Pretoria to hear what he’s been up to.

An HIV doctor working for a nongovernmental organisation in Eshowe tells an interesting story about a visit from Yogan Pillay in 2019. Their HIV project had managed to achieve the UNAids 90-90-90 targets (90% of people with HIV know this diagnosis, 90% of those diagnosed are on treatment, and 90% of those on treatment have achieved suppression of their virus) in a fairly large population, and Pillay, who was responsible for the country’s HIV programme at the time, had journeyed to Eshowe to find out how they had done it.

“We heard that he doesn’t mince his words, so everyone was standing a little straighter than usual,” the doctor says. 

The team had expected a cavalcade of luxury vehicles but around the corner came an inexpensive hire car, which Pillay himself was driving. His first order of business was to ask to be introduced to all the nurses present.

“That put everyone at ease. But the moment he was done he turned to me and said, OK, now tell me how you did it, and I’m warning you, if the secret is money, I’m not interested,” the doctor recalled.  

I was reminded of this story when I visited Pillay at his home in Pretoria East in November. Pretoria is home to many current and former government leaders, most residing in luxury in highly securitised compounds. The housing estate I pulled up to was nondescript. There were no guards controlling access – Pillay himself let me in. Standing in the doorway of his townhouse in a T-shirt and shorts, he ushered me out to the covered stoep in hushed tones.

“My son is studying for his [matric] exams, he doesn’t like a lot of noise,” he says, offering food and a hot drink. His son, Vishay, had been provisionally accepted into four medical schools.  

Yogan Pillay On the run: Yogan Pillay racing the Om die dam (around the dam) Hartbeespoort half-marathon in 2003. ‘I go to the gym at least three times a week, and still run, but mostly on the treadmill,’ he says. ‘I’m also a vegetarian.’ (Photo: Supplied / Bhekisisa)



“The only things I’m proud of are my son, my publications, and my work in the department,” Pillay says, as a kind of opening statement. Then, after a pause, he said he felt sorry for me. 

“I have no idea what you’re going to write about. My life story isn’t particularly interesting. I mean, very little that has happened in my professional life has been by design. I’ve been fortunate, really.”

Extreme modesty usually signals rich pickings for the writer of personality profiles, but Pillay insisted he would be the exception.

But I had already talked to enough people in South African healthcare circles to know it wouldn’t pan out that way. Pillay, I was told, was hard-working (to the point of being a workaholic, some said), practical, strategic, communicative. But there were other words, too: acerbic, meticulous and stringent.  

I mentioned the Eshowe story as a case in point. He chortled.

“It’s super important to engage with the frontline staff, and my concern is that we don’t engage them enough. I am as much to blame as anyone. When I was sitting in the national department, developing policies, who would we call for input? We would call all the academics… often forgetting about the healthcare professionals who have to implement the policy, and the people who use the services.”

Pillay would become known for his insistence that healthcare models be grounded and practical. Quite a few of the department’s nongovernmental partners will recall being chastised by him for coming up with innovations that were impossible to implement at scale, being unaffordable, or otherwise unacceptable.

“I probably get that from my dad, you know, he was a real stickler. His ethos was basically that you’ve got to be able to take things on, apply yourself, and get the work done in the most practical way. Never leave a thing half done.”

Eyes on the prize: Yogan Pillay matriculated from Raisethorpe High School in Pietermaritzburg in 1975. Here he receives the prize for the second-best academic student in his class. (Photo: Supplied / Bhekisisa)



Yogan Pillay Bookish: Pillay co-authored two textbooks on global health, co-edited books on mental health and on the South African health system and dozens of peer-reviewed journal articles. (Photo: Supplied / Bhekisisa)


Child of the Hibiscus Coast


Born on a farm outside Port Shepstone, Pillay was one of four children. He describes his parents as “grafters”, who “got it from their parents”. His maternal and paternal grandfathers, respectively from India’s merchant and farming classes, arrived in South Africa with nothing, and became relatively prosperous, buying shops and farms.

“My maternal grandfather was a real entrepreneur. He had the first Buick on the south coast of Natal,” says Pillay, who attended the local farm school before moving across to RA Engar school in Marburg – “Port Shepstone’s Indian area” – when his father took a teaching post there.

Pillay continued to the Indian High School in Port Shepstone but moved to Pietermaritzburg when his father was appointed headmaster of a school there. 

“I attended Raisethorpe High, where all the teachers were Indian. They were very straight, you couldn’t mess around, and of course they all knew my dad, so I had to behave,” he says.

After matriculating, Pillay applied to study medicine at the University of the Witwatersrand and was accepted.

“As a non-white I needed ministerial permission, which I duly received, but I couldn’t stay on campus, which posed a problem because neither I nor my parents had ever been to Johannesburg. My dad got one of my cousins to drive me up, and we started looking for accommodation.” 

Student life: A Kellogg scholarship took Pillay to the Johns Hopkins Bloomberg School of Public Health in the US, where he would finish his PhD before returning to South Africa. (Photo: Supplied / Bhekisisa)



Eventually, he located a relative “a couple of bloodlines over”, who allowed him to sleep on the couch in her home in Lenasia. He found it deeply uncomfortable.

“Those four-room houses in Lens had a toilet outside but no bathrooms. To shower you had to go to another house a few streets away. I never understood why the apartheid government would build houses with a toilet, but no bathroom. It’s very curious,” he says.

To get to his lectures, Pillay would bus into the city early in the morning, and walk through Braamfontein cemetery, repeating the long and prosaic journey at the end of the day. He was miserable. He dropped out after a year, enrolling instead for a bachelor of science at the University of Durban-Westville, where he “did rather better in psychology than physiology or biochemistry”, leading him to apply for a place in the University of Natal’s clinical psychology programme.

There he completed an honours and a master’s, and gained both inpatient and outpatient experience on rotation through Fort Napier, Townhill and Northdale hospitals. He worked in clinical psychology in Pietermaritzburg for three years and then lectured at his alma mater for three years before deciding to do a doctorate.  

Levelling up


A Fulbright scholarship to study community psychology at New York University (NYU) landed Pillay in Washington Square in midtown Manhattan, “with two big bags, very little money and no idea where to find the [NYU] housing department”.

The course wasn’t what he hoped it would be.

“They could only teach me statistical analysis. Thanks to the grounded experience I had in South Africa, there was not much left to learn from a community psychology point of view,” says Pillay, who was also struggling to make ends meet in New York, where his rent bill for a shared apartment chewed up three-quarters of his stipend.

He won a Kellogg scholarship – “more money” – and moved to Johns Hopkins University in Baltimore, to study under Spanish sociologist and political scientist Vicente Navarro. In 1995 Pillay finished his PhD and decided to return home.

“Quite fortuitously, the national department [of health] had advertised some positions, one being the director for health systems role. I applied, got it, and moved to Pretoria in 1996,” says Pillay, who found the environment “at least as intimidating as New York”.

“It was still very white, everybody walking around in grey shoes, and all that,” he says.

Talk at 10: Pillay was the keynote speaker at Bhekisisa’s 10th birthday celebration in November of 2023, where he spoke about how the climate crisis is a health crisis. (Photo: Delwyn Verasamy / Bhekisisa)



After three years of office-based work, Pillay was feeling removed from the healthcare realities on the ground. A US-based NGO called Management Sciences for Health had offered Pillay the reins of a project to strengthen primary healthcare in the Eastern Cape. Rather than lose Pillay, the department’s then director-general, Ayanda Ntsaluba, allowed him to keep his office, and split his time 50-50, “with the proviso that they [the American NGO] pay my salary”.

He led that project – the Equity Project – later taking the job of chief director for strategic planning in the national department and then deputy director for health programmes. 

In that vast role, which he held from September 2008 to May of 2020, he oversaw the HIV and Aids, TB and maternal, child and women’s health programmes. It would be the making of Pillay. 

In his time, mother-to-child transmission of HIV dropped from 6% to under 1%, and the number of people on antiretrovirals rose from about 350,000 to more than five million. Between 2008 and 2018, life expectancy in South Africa increased by 10 years.

“In 10 years it increased by 10 years, a thing for which there was no precedent anywhere in the world. Of course there were other factors in play, like the government pushing forward on education, access to clean water and sanitation and all of that, but by all accounts the major contribution to expanding life expectancy was the significant increase in the number of patients on antiretrovirals.” 

An extraordinary thing to be able to claim to have had a hand in, but context is important. Before 2008, a high number of avoidable deaths – in the hundreds of thousands, at a conservative estimate – had occurred as a direct result of healthcare policies that prevented people living with HIV from accessing antiretroviral drugs. These policies were largely a manifestation of the Aids-denialist views of President Thabo Mbeki and his health minister, Manto Tshabalala-Msimang. While Pillay was not directly responsible for the HIV programme under Mbeki, there are those in the treatment activism community who are yet to forgive his failure to speak out. 

One HIV doctor I spoke with bitterly recalled being admonished by Pillay after he allowed members of the Treatment Action Campaign to protest outside a clinic Tshabalala-Msimang was due to visit.

Pillay shrugs his shoulders when I bring this up.

“Manto insisted that a long list of criteria be met before patients could be initiated on treatment. My colleague Nono Simelela, who was head of the [HIV] programme at the time, found her [Tshabalala-Msimang] to be completely unyielding, and so we took a decision to quietly allow treatment to be provided where possible, under the noses of Manto and Thabo. Western Cape did it, and KwaZulu-Natal did it, but generally speaking the provincial MECs [for health] were scared,” Pillay says.

Changing of the guard


Within months of Pillay taking on the DDG role, Mbeki was replaced by Jacob Zuma as president, and Aaron Motsoaledi took Tshabalala-Msimang’s place as health minister.

It is clear that Pillay has a lot of time for Motsoaledi.

“He [Motsoaledi] likes big ideas. In fact, he has a tendency to make them even bigger than you envisaged,” he says.

For starters, Pillay and his team wanted more money for HIV. A lot more.

“We consistently used data to get the Treasury to give us more money for HIV and to show programme progress. We especially focused on incidence and mortality data. 

“We said [to Motsoaledi], if you want to decrease incidence [the rate of new infections] and mortality of HIV, the best evidence we have through a model is that you need to test and initiate [on treatment] a certain percentage of people, and this is what it will cost us to do that in South Africa. 

Motsoaledi approached the president with this argument, and Zuma took it to Pravin [Gordhan], who was the minister of finance, and said go find the money for these guys. So Pravin went and top-sliced from all other government departments to give us the conditional grant for HIV,” says Pillay.  

On a structural level, the idea was that HIV treatment should become a primary healthcare service rather than a hospital-based service, with nurses managing patients instead of doctors. Motsoaledi hardly needed convincing.

“He approved it, the nursing council approved it, and we moved the entire programme out of hospitals and into clinics, and from this new footing we saw large numbers of people being initiated,” Pillay says.

To radically expand HIV testing and counselling, Pillay pitched what many regarded as an impossible idea. 

“It became known as 15 in 15 – 15 million tests in 15 months. A lot of people said that was mad, but we were able to do that.”

Moving to the outside


When Pillay resigned from the department in 2020, the gossip on the wires was that it was in reaction to being passed over for promotion to the director-general position, a theory Pillay rubbishes, insisting that he is “a technical person through and through, not a politician”. 

“I have a very simple recipe that I’ve been using for years now. Make sure that you know your numbers, that’s important. Be sure to have a strategy, and an implementation plan. Then, do your monitoring.”

That year Pillay joined the Clinton Health Access Initiative as its country representative and global adviser on universal health coverage. But towards the end of 2022 he received a call from South African expatriate Trevor Mundel, one of the presidents at the Bill & Melinda Gates Foundation.

Mundel said he was looking for somebody with experience in delivering health programmes, specifically for TB and HIV. 

“I thought he was just asking for my advice, so I told him I thought it was a good idea, because while I was with the department we were forever criticising the foundation for developing shiny new things without really bothering to work out how they’re going to get them to the patient,” Pillay says.

When Pillay realised that he was being offered a job, he hesitated.

 “I said, ‘I’m not sure that you guys are serious about delivery, you know?’” 

He relented after learning that he would be working with former UNAids executive director Peter Piot, who had been brought into the foundation as an adviser.

“I knew Peter from my HIV work and said I’d join him on one condition: that I remain working from South Africa, because all our work is in this part of the world. So here we are,” he says, a relaxed smile creasing the corner of his eyes. 

Pillay is not the first senior Health Department figure to have joined a major international player (former TB director Lerole David Mametja was in a senior role at TB HIV Care from 2019 to 2023), and he will not be the last, but it is a career move that raises eyebrows.  

Speaking on condition of anonymity, a senior policymaker in government told Bhekisisa that “health planning has never been politically innocent or ideologically naïve. Those organisations that we call development partners are not innocent, and owing to their financial power they are able to impose their own strategic goals, to the extent that if we are not careful our senior leaders become functionaries of those funders, both when they are in service and out of service.”

Pillay is happy to tackle the insinuation.

“There are pros and cons to philanthropy. I think it is good to be sceptical. I think it’s fine if donors fund innovations that governments can take to scale, feasibly, and I think it’s fine if they function as thought leaders, but donors should not be funding routine services. That’s how dependency happens. A country like South Africa should not be dependent on donors,” says Pillay.

One of the awards Pillay received over the years was from the KNCV Tuberculosis Foundation for his work in combattng TB. (Photo: Supplied / Bhekisisa)



It could be the casual attire, but Pillay does not seem to be a man caught in a web of contradictions.

South Africa is doing poorly on HIV compared with other countries in the region, and improvement will not happen in the absence of strategic partnerships, Pillay believes.

“I think there are a number of factors. Quite a few experienced people have left the department, and there are a lot of people in acting positions, and when you’re acting in a position it’s difficult to take decisions,” he says. Relations between the national department and the provincial departments of health need to be improved, too.

“The provinces will only take your guidance if they trust you, and if they think what you’re telling them makes sense,” says Pillay, who reached out to Motsoaledi after his reappointment as health minister in July 2024, offering his assistance.

Not too long afterwards, Motsoaledi convened, with foundation funding, a retreat for senior healthcare leaders from the national and provincial governments, at which a plan was devised for, in Pillay’s words, “moving the needle on strengthening management, improving health outcomes, strengthening facility-based service delivery and dealing with human resources issues”.

Pillay has also been working with both the department and Pepfar on a plan to put an additional 1.1 million people on treatment in 2025, to help the country reach the UNAids 95-95-95 targets [the plan was announced by Deputy President Paul Mashatile on World Aids Day in 2024].

“Like we did with the 15 in 15, the plan is to have a high-level team drive this,” he says, and my surprise at the extent of his influence must show, because Pillay quickly adds: “Look, I’m an insider outsider. I have worked in the department, the minister knows me.”

With the future of US government funding to global health in doubt under the Trump administration, and given that South Africa’s HIV programme is heavily dependent on Pepfar and the Global Fund, a person with Pillay’s experience and contacts, to both government and donor organisations, is easy to understand.

At the close of many an interview comes the moment one asks to be able to take a photo or two. Never less than awkward, I had been particularly dreading asking Pillay, who was clearly having a day off, recuperating from a long flight.

“Sure,” he says, “just leave out the shorts.” DM

Full disclosure: The Bill & Melinda Gates Foundation is a donor to Bhekisisa. This article was, however, commissioned without the foundation’s approval or input. 

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.


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