Dr Aaron Motsoaledi, minister of health, was once a family GP. He is a warm, affable man who must have had a pleasant bedside manner as a doctor.
"And when I ran my practice, there were no co-payments," he says of his former rooms in a rural town in Limpopo.
In an interview this week, Motsoaledi says repeatedly that it is an anomaly that South Africans should pay for health services in addition to their medical aid premiums. He is referring to one of many contentious aspects of the healthcare reform he is spearheading.
Two bills, the National Health Insurance Bill and the Medical Schemes Amendment Bill, have been gazetted as precursors to NHI coming into effect. Scrapping co-payment is the least drastic of the changes, which start at academic level and extend into the spheres of human resources and procurement policies.Motsoaledi says he understands why some people think he is mad. Others say NHI is a political move, and a hasty one, ahead of next year's national election.
CHALLENGING AIDS DENIALISTS
He was an activist in his teens, with links to Umkhonto weSizwe even before he was a medical student at the then University of Natal. In April 1994, he hung up his stethoscope to work in the government, running provincial education, transport and agriculture departments.
Known for challenging the denialism around HIV/Aids in the Thabo Mbeki era, he was made minister of health in 2009 to clean up after Manto Tshabalala-Msimang's African potato and garlic mess.
The medical fraternity locally and worldwide, along with anxious health journalists who camped outside his new office, hailed his science-based stance on HIV/Aids and the way he set about tackling South Africa's burden of disease.
Motsoaledi is known for receiving his personal healthcare at a state hospital.
His legacy will include the roll-out of antiretrovirals, which have cut the mortality rate of HIV-positive people by 47%.
But the past few years have been marked by systemic failures, frustration among overworked or unemployed doctors and nurses, irregular spending, and a health system in which people queue hours for basic care.Incorporating the private sector into this system seems diabolical. With just under a year to go until the end of his second term in office for Motsoaledi, NHI might shift his image from Dr Fix-It to Mr Hyde.
HOT-UNDER-THE-COLLAR SYNDROME
At the ANC's 2007 Polokwane conference he was handed a brief to implement the mammoth free healthcare campaign. He calls it the healthcare version of the land debate, and privileged South Africans are up in arms.
Private and public healthcare professionals, medical aid providers and clients are calling code red, but Motsoaledi is hearing none of it.
With a nine-year stint as health minister behind him, some might say Motsoaledi is responsible both for the current state of the country's healthcare system and for implementing what they fear will be its dystopian future.
But Motsoaledi believes that NHI, which the government aims to implement by 2026, will bring equality to a system that everyone agrees is in dire need of restructuring.
The aim is to provide healthcare that is free at the point of delivery and that all South Africans contribute to, depending on their ability to do so, which in essence means the rich and healthy provide for the poor and the sick.
Because the plan is in its embryonic stages, it is not clear what effect it might have on the way medical aid works. How it will be paid for has yet to be finalised, but the bulk of funding will come from state coffers, says Motsoaledi.NO PRICE IMPACT ON PRIVATE CARE
"Firstly, in all likelihood it should not increase the cost of private healthcare, I am dead sure about that. The NHI, free education, pensions ... will always be funded by the state, which comes from the four tiers of tax."
He thumps the table for emphasis: "Please, with every muscle in my body, understand one thing. That tax includes individuals, corporate, surcharges and VAT — which means the poor are also going to pay, proportionately more than others."Motsoaledi's argument is that the healthcare system is unfair and unequal no matter from which side of the spectrum people access it.
"Let me tell you the problem with South Africans on this issue. We have an extraordinarily expensive private health service on the one hand. You believe the minister is a madman to talk about it. You don't believe the fees are too high, but it is blackmail what private healthcare charges. It is unregulated and it is robbery.
"On the other hand, there is the poor quality of the public health sector. Everyone blames the minister, but it is [complex]. That is why we talk about massive reorganisation of the healthcare system."
With 16% of the country on private schemes and 84% using public healthcare, reform is necessary to bring quality care to everyone.
Most say to try to do so is idealistic — and unrealistic.
Motsoaledi says he understands the problems that caused health departments in eight of the nine provinces to be placed under administration by the National Treasury. While advocacy groups, the private sector and even state medical staff lay the blame at his door, he blames the co-operative governance structure that places budgets, hiring of staff and procurement in the hands of MECs as the primary issue."The Life Esidimeni tragedy is the result of this. Things happening in quiet corners without national government knowing about it. That needs to change urgently," he says.
SHORTER LEASH FOR THE PROVINCES
Among the major changes provided for in the NHI plans is that hiring and procurement will be removed from the hands of provincial governments.
"Everyone says: 'But you are the minister, you must demand!' Yes, I am the minister, but I have no legal rights in the provinces, only a moral responsibility to create policy. Funding goes from Treasury to the provinces, and it has caused many problems.
"To the public it sounds out of this world. But that is why we have put 'airline quality' standards in place, and we are saying to our hospitals and clinics, please get used to them at that level."
He uses various analogies, including comparing private health to designer suits that inexplicably cost 10 times what they are worth."The example of the airlines I use, because one small mistake can mean that all 300 people on board are gone. They are used to certain routine standards, drill, and repeat it with such monotonous repetition without getting bored because you can't take off otherwise.
"The hospitals seem to get bored of these checks. We are trying to drill them. Our hospitals and clinics are not used to it. We wanted to start a journey that these issues of process are very important to make NHI work," he says.
Among his achievements Motsoaledi lists the establishment of the office of health standards compliance and, within that, the creation of a health ombud.ZERO TOLERANCE FOR DIRTY LOOS
The OSHRC recently assessed about 700 public health facilities under its stringent standards — and all but five were found wanting.
"I am quite aware that people are up in arms about the failing of the hospitals. We did not establish the [OSHRC] to prove we will pass with flying colours. We established it because there are huge problems.
"Perhaps we made a mistake by announcing the office to the public while it was fine-tuning itself. You don't set lower standards for yourself and come to the public and say: 'We passed with flying colours.' Some of the scoring is difficult for an ordinary member of the public to understand."
He gives the example of a hospital failing because it had one dirty toilet out of 100.
"It doesn't mean the hospital can't operate, but we say the standard is that it is vital that every toilet in a hospital has to be clean. If they have 100 toilets you don't need all 100 to cause an uncontrollable spread of disease. You need just one," he says.
"When they go to inspect, if they find just one dirty toilet, they give you a zero. To the public it's as if 'Oh, this hospital is so dirty'. It's not. It means we expect 100% cleanliness on toilets. This is the example of how the standards work, we want them to get used to that."Motsoaledi says the biggest challenge is staff shortages. "It gives me nightmares. I am really trying my best to plead with provinces to employ people."
PROVINCIAL PRIORITIES
He explains that the provinces failed dismally to fix staff issues, for various reasons - including the Western Cape hiring only 57% of the medical interns allocated to it because it had diverted funds to dealing with the drought.
"Generally sub-Saharan Africa is short of staff. But the situation is that when provinces are in financial trouble they start cutting down, creating a moratorium on hiring. We don't hire at national level. I argued in parliament that even if we are in financial trouble ... you can't cut at the coalface of delivery: doctors, teachers. The national committees agreed," he says.
The Esidimeni tragedy is a drastic example of an attempt to save costs. The consequences were "disastrous", Motsoaledi says.
"When Treasury takes over a department that is under administration, the first function they take over is human resources. That is the sensitive heartland of service delivery. You can't deliver service if you have the medical equipment but you have no people. That's where they hit hard."That is why in NHI we are proposing a special committee to do the hiring. I am not saying I want to take over, but it must not be in the hands of provinces, because it is not working," he says.
THE ELEPHANT OUTSIDE THE ROOM
Motsoaledi takes a minute to make light of the fact that he visits the Pretoria Zoo "for free" — it is next door to his office building, and he can spot animals from his window on the 28th floor. He tries to point out an elephant to me, but I strain to see it.
Eventually, it comes into focus, and he laughs heartily.
Motsoaledi is sharp, or he would not have lasted in his role. He sees the issues and is aware of how to fix them.
But the state of healthcare seems to show that the department has failed to keep up. There are those who say it need not have taken nine years for him to act against the provinces.The minister says he is invested in the reform. Politically, definitely. Personally too. His daughter, the eldest of his five children, is a community service doctor who may also have to fight for her place in the system. He says he has not discouraged her from pursuing her career despite the healthcare challenges.
FOUR AREAS OF CONCERN
"There seem to be many issues, but there are four categories: human resources, financial management, procurement and management of infrastructure, and maintenance of equipment.
"Those are the areas where we want huge changes and they have caused all these disasters: Life Esidimeni, Mediosa [the Gupta-linked mobile clinic scandal in North West], the national oncology crisis ... they all fall within these four," he says.
The budget for NHI has yet to be confirmed, but Motsoaledi says initial estimates of R259-billion were a thumb-suck by a local accounting firm.
"We made a mistake with the figures. I then went for advice to the World Bank and the World Health Organisation and they asked why am I trying to do this, it can't be quantified by any human being because the costs are so variable."
NHI may be idealistic, but so was the #FeesMustFall movement. The quid pro quo for the latter was the VAT increase.
"You cannot balance books against service delivery on human life," Motsoaledi says.
"I am not saying money must be used wrongly. The audits must be passed, but saving money at the expense of human life ... we can't do that any more. You saw what happened at Life Esidimeni."
For now, he will continue to implement the NHI policy for as long as "the party decides" to have him in office.
"Look, it doesn't mean anything if the minister changes. It doesn't matter as long as the poor get healthcare, that is what we need from NHI."
Whether NHI is introduced successfully or not will be part of Motsoaledi's legacy.
We should all hope the results will not be a "Manto moment" that will take another generation to fix...