When South Africa's democratically elected government came into power in 1994, it faced many challenges left by the apartheid regime, and the health department was no different. It had to integrate a segregated health system divided along racial lines and extend healthcare to all. Each president and his respective health minister made broad changes to the South African health system – from Nkosazana Dlamini-Zuma's introduction of progressive tobacco legislation and Manto Tshabalala-Msimang's notorious Aids denialism to Aaron Motsoaledi's radical upscaling of HIV treatment.
But who achieved what and who failed at what over the past two decades?
Nkosazana Dlamini-Zuma, 1994–1999 (under then president Nelson Mandela)
Mandela's mandate that primary healthcare should be free to pregnant women and children under six started to be implemented by Dlamini-Zuma in 1996.
"There was huge opposition to this policy because there were not enough facilities, especially those located in underserved communities, to accommodate it," the head of the Human Sciences Research Council (HSRC), Olive Shisana, who was Dlamini-Zuma's director general of health at the time, said. "She began to implement it where facilities existed and also built as many new clinics as she could."
Between 1994 and 1998, 500 new clinics were built, 249 clinics had major upgrades and 2 298 received minor upgrades, according to Shisana.
In 1996, under Dlamini-Zuma, the Choice on Termination of Pregnancy Act was passed, legalising abortion.
Shisana said it was "really difficult" to get this Act through Parliament: "People were saying: 'In our culture, we want children and abortion is not acceptable', and religious groups also opposed it."
According to Shisana, Dlamini-Zuma "may have disagreed with abortion herself but, as the health minister, she couldn't sit back while women were dying because of backstreet abortions".
Dlamini-Zuma introduced radical changes in tobacco policy, including passing legislation for mandatory health warnings on cigarette packets, restricting smoking in public places and banning tobacco advertising.
"At the time, it was the best and most progressive anti-tobacco legislation in the world," said Yussuf Saloojee, from the National Council Against Smoking.
Dlamini-Zuma's term as health minister coincided with the growing HIV epidemic, which had been ignored by the apartheid government.
"At the time we didn't have access to antiretroviral [ARV] medication like we do today, so we had to focus on preventative measures," said Eric Buch, dean of health sciences at the University of Pretoria, and deputy director general for health in Gauteng from 1995 to 1999.
This resulted in the commissioning of Sarafina II, a R14.27-million play in 1995 to educate people about HIV, directed by celebrated playwright Mbongeni Ngema, which was clouded in controversy as proper tendering processes were not followed and the play contained very little HIV information.
Another scandal was Dlamini-Zuma's endorsement of a toxic industrial solvent, Virodene, which University of Pretoria researchers claimed could kill HIV in human bodies, in 1997. It was a wild claim: no trials had been conducted to establish the product's safety or efficacy. Soon after the Medicines Control Council blocked clinical trials of the drug because of ethical and safety and concerns, its chairperson, Peter Folb, was fired.
"While the Virodene scandal goes much wider than Dlamini-Zuma, she did play a key role by providing support to the researchers and facilitating meetings with Cabinet. Her gullibility foreshadowed the unscientific and overly politicised approach to health that would cost many lives in future years," said Marcus Low of the Treatment Action Campaign (TAC).
"Her motives for engaging with Sarafina II and Virodene were essentially the same – she wanted to address the HIV epidemic, even though it was done in a misguided manner," Shisana said.
Manto Tshabalala-Msimang, 1999–2008 (under then president Thabo Mbeki)
Her term was a "dark period" for health in South Africa, especially regarding HIV, Salim Abdool Karim, the head of the Centre for the Aids Programme of Research in South Africa, said.
Mbeki's scepticism about whether HIV caused Aids, as well as his beliefs that ARVs were dangerous, were adopted by Tshabalala-Msimang, thus delaying treatment for the growing number of South Africans with HIV.
The TAC took Tshabalala-Msimang to court in 2001 to provide HIV-positive pregnant women with the ARV nevirapine, which could halve the chances of transmitting the virus to their babies. The TAC won the case, but Tshabalala-Msimang "was still obstructive in implementing this programme", according to Karim.
Finally, after a 2004 Cabinet decision forcing the health department to provide HIV treatment, it began to roll out its ARV programme.
Harvard University researchers from the United States estimated that more than 330 000 people died between 2000 and 2005 as a direct result of delaying the state-implemented ARV programme.
Tshabalala-Msimang was derided for promoting a diet of garlic, beetroot, lemon and African potato for people living with HIV instead of ARVs. "As a medical doctor, she should have been able to stand up to Mbeki with facts. The problem was she didn't have an independent mind," Karim said.
She implemented the tobacco legislation passed under Dlamini-Zuma. This included stipulating that public places could designate only 25% of their premises to smokers, but it had to be blocked off from the other sections. She closed up loopholes in the banning of tobacco advertising, making one-to-one advertising illegal.
Tshabalala-Msimang made some positive changes, but "these will always be overshadowed by her Aids denialism", Karim said.
Aaron Motsoaledi, since 2009 (under President Jacob Zuma)
"Motsoaledi brought integrity back into the health ministry," Buch said.
Under him, access to ARVs almost doubled between 2008 to 2012, with about two million people on treatment in 2012, according to the HSRC's latest HIV report.
The health department says this figure increased to 2.4-million in 2013, making it the biggest ARV programme in the world.
"We're now on the path to eliminating mother-to-child transmission of HIV," Karim said.
According to the Joint United Nations Programme on HIV, between 2009 and 2012 there was a 46% decrease in new HIV infections in children.
Life expectancy also increased from 53 in 2002 to 60 years in 2013, according to Statistics South Africa, largely owed to the ARV programme.
Earlier this year, Motsoaledi introduced a vaccine against cervical cancer to all grade four girls in public schools. He negotiated a greatly reduced price for the vaccine – one-fifth of what it costs in the private sector (R595) – from manufacturer GlaxoSmithKline.
In response to the ballooning tuberculosis (TB) epidemic, 203 state-of-the-art GeneXpert machines have been introduced at facilities around the country, according to the TAC and Section27. This machine significantly decreases diagnosis time and can detect drug-resistant TB.
The policy that has created the most controversy, while also garnering widespread support, is Motsoaledi's proposed National Health Insurance (NHI) scheme, which aims to solve the vast inequalities between South Africa's private and public heath sectors. It will take 14 years to implement.
"Fundamentally, you need to be a pretty strong and gutsy person to take on several interest groups to push through the NHI – and he's doing that," Karim said.
The project began with the introduction of 11 pilot sites in 2012. But the TAC and Section27 have criticised them and said they are largely dysfunctional. They said in a 2013 report that "most of the district administrators, facility managers and healthcare workers were unclear about what the NHI piloting phase hoped to achieve or what they were expected to do".
Although Motsoaledi has been responsible for many advances since 2009, Karim said that "the healthcare system as we look at it today is not really that much better in service delivery than it's been before". Healthcare facilities are run by provincial departments and national policies are often not realised "on the ground", he said. "There is only so much the health minister can do."
Progress towards achieving some of the 2015 United Nations millennium development goals has been static. Maternal mortality is not decreasing at rates that will see South Africa reach the goal of 38 deaths per 100 000 live births – the current figure is almost seven times that at 269, according to Stats SA.
But we are closer to achieving others: in 2011, there were 53 deaths per 1 000 in children under five and the target is 20.
Should there be a Cabinet reshuffle after the elections, Karim said he hopes Motsoaledi is reappointed and "gets the chance to see the policies he's implemented, specifically the NHI, through to completion".
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