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The National Health Insurance (NHI), for which membership will be compulsory, is a funding scheme that aims to address healthcare inequity in South Africa. The scheme will do this by creating a fund that the government will use to buy healthcare services at set fees from accredited public and private health providers. The NHI Act was signed into law on 15 May 2024 but before it will come into effect, Parliament will need to enact further legislation (including ones providing for its funding).

HomeSpecial ReportsNational Health InsuranceEight things Motsoaledi and Phaahla have in common

Eight things Motsoaledi and Phaahla have in common

  • Does he have the skills? And what allowed him, rather than Joe Phaahla, to land the position of health minister?
  • Mia Malan writes it was likely just plain, practical reasoning: Motsoaledi has more experience as a cabinet minister and he’s slightly more senior within the ANC than Phaahla.
  • But our minister will have to make tough choices: those who don’t perform, will have to go.

In today’s newsletter, editor-in-chief Mia Malan looks at whether Health Minister Aaron Motsoaledi can pull off the NHI. Sign up.

COMMENT

What allowed Aaron Motsoaledi, rather than Joe Phaahla, to land the position of health minister in South Africa’s 2024 government of national unity? 

And why was Phaahla, South Africa’s health minister until the end of May, demoted to being a deputy minister rather than Motsoaledi, who had to give up his home affairs minister post to make way for the Democratic Alliance’s (DA) Leon Schreiber? 

We can throw a lot of arguments around about Motsoaledi’s and Phaahla’s respective seniority within the African National Congress (ANC), their levels of support for the party’s ANC president, Cyril Ramaphosa, and whose health policy advice the ANC’s national executive committee (NEC), of which both Phaahla and Motsoaledi are members, will take more seriously. 

But ultimately, there’s likely no mystery reason for Motsoaledi’s appointment; rather plain, practical reasoning. 

Motsoaledi has more experience as a cabinet minister than Phaahla (15 vs. three years), he received more votes than Phaahla in the NEC (Motsoaledi ranks number 27 vs. Phaahla’s number 51) and, together, they will make a formidable team, from an ANC perspective, to push through the party’s flagship health strategy, its National Health Insurance scheme (NHI), which Ramaphosa hastily signed into law two weeks before the May general elections. 

There’s also context: Phaahla isn’t the only ANC cabinet minister to get demoted to deputy minister to make way for a DA candidate. Two others — Sihle Zikalala, former minister of public works and infrastructure, who is now the deputy minister and Mondli Gungubele, our previous communications minister who is now the deputy minister in that ministry — faced the same fate. 

What is, however, different in Phaahla’s case, is that he wasn’t making room for a DA minister in the health ministry like Gungubele, Zikalala and Motsoaledi had to do in their ministries. Instead, Phaahla had to make way for someone — who frequently made unpopular decisions as home affairs minister — Ramaphosa wanted to keep in his cabinet.

But, even here, the decision was probably simply pragmatic.

HEALTH BEAT #20: 3 DECADES, 6 HEALTH MINISTERS

The ANC has fought tooth and nail, also in the provinces, to keep health ministries under their rule; and they’ve succeeded in all provinces but the Western Cape, which is ruled by the DA. 

Where better to send Motsoaledi, likely the ANC’s strongest NHI supporter, than the national health ministry, where he’s previously served, to work along with someone with whom he’s got a four decades-long work history? 

And Phaahla and Motsoaledi, both ANC and health department insiders say, will work together exceptionally well, as they always have.  

Here’s why.

Motsoaledi and Phaahla have a lot in common

Motsoaledi and Phaahla’s personal lives and careers have striking resemblances.

They’re both in their late sixties, hail from Limpopo, studied medicine at the University of Natal during the late 70s and early 80s, and, as senior ANC leaders took an exceptionally strong, public stance against state capture in 2016 and 2017 — while they were, respectively, also health (Motsoaledi) and deputy health minister (Phaahla) — by supporting motions of no confidence against the ANC’s former leader Jacob Zuma.

Neither Motsoaledi nor Phaahla are associated with incidents of personal corruption and both are strong allies of their party leader and the country’s president, Cyril Ramaphosa. 

But, most importantly, they’ve a 40-year long history of working with each other — and, particularly when they were younger, Motsoaledi didn’t invariably lead Phaahla; it was often the opposite way around. 

As student leaders, for instance, Motsoaledi, as the national correspondence secretary of the Azanian Students’ Organisation, served under Phaahla, who was president, although they were both founding members

In 1997, after both had served as MECs for three years in Limpopo’s first democratic government, former premier Ngoako Ramatlhodi axed Motsoaledi as education MEC and replaced him with Phaahla (who was health and welfare MEC at the time). The reshuffle resulted in Motsoaledi becoming an ordinary member of the Limpopo legislature.  

But when Motsoaledi and Phaahla were both elected as National Assembly members in 2009, their careers started playing out with different levels of seniority. 

Motsoaledi became health minister straight away, while Phaahla occupied deputy minister positions in various departments for the following 12 years, with only a short, much later stint as health minister between 2021 and 2024, when former health minister Zweli Mkhize resigned because of corruption allegations and while Motsoaledi was home affairs minister. 

For eight of Motsoaledi’s ten years as health minister between 2009 and 2019, Phaahla served as his deputy, as he is now again. 

Will the GNU allow the roll-out of the NHI? 

Motsoaledi faces a massive challenge: preparing to roll out a controversial NHI Act, which already faces six separate legal challenges, by a government of which only four out of 11 parties that govern support the legislation.  

The GNU’s second largest party, the Democratic Alliance, will be a particular dilemma, as their own health policy is based on expanding access to medical schemes — in stark contrast with the Act, which says medical aids have to be scaled down to only provide services not covered by the NHI, so that money paid towards private health insurance could instead be used to pay for the NHI.  

MIA MALAN SPEAKS TO NEWZROOM AFRIKA ABOUT THE NHI ACT

The Act, which has been assented, but still has to be proclaimed, is in many ways, Motsoaledi’s “baby”: as health minister between 2009 and 2019, he oversaw the development of the NHI white and green papers as well as the NHI Bill. And although critics have slammed all three documents for being “irrational and incomprehensive”, not incorporating the views of those who made submissions and being unconstitutional, Motsoaledi has made it clear he believes the NHI is the best solution to South Africa’s health system problems

Not only would he need to get GNU parties to work with him, he’d also need to ensure the national health department writes timely regulations for different parts of the Act and get the cabinet to approve them. Moreover, he’d have to drive the process of amendments to at least 10 other Acts, which are required in order for the NHI to be rolled out, including changes to the Medical Schemes Act, which the DA and parties such as the Freedom Front Plus, are likely to oppose.  

But, most importantly, Motsoaledi would need the treasury to allocate him a sufficient budget to cover the cost of rolling out the scheme — or the scheme will never get off the ground. That could be anything between R200- and R500-million a year, depending on whose predictive calculations you use. Essentially, nobody knows the cost, because it’s unclear which services the NHI would provide.  

How much NHI money is in the 2023/4 health budget? Find out.

And, both health department and treasury insiders say, finding the money could be tricky, as there are several senior leaders within the treasury, who have voiced their direct opposition to the NHI.

How will Motsoaledi shape up? 

Motsoaledi is an outspoken politician, much more so than Phaahla. He’s voiced his distrust of the (unregulated and overpriced) private health sector, and during his previous tenure commissioned a health market inquiry into the sector, on which a final report with far-reaching recommendations was published during his last year as health minister, in 2019 — but he never acted on it. 

His xenophobic views — Motsoaledi has blamed undocumented migrants (at least partly) for the overburdened state of the country’s health system and some of his home affairs policies were seen as “anti-immigration — are problematic, particularly within the context of the NHI and migration becoming more common because of the consequences of climate change. 

But Motsoaledi isn’t all about controversy. 

He’s also human, and principled. For one, he had the guts to stand up against the president who appointed him by supporting motions of no confidence against Jacob Zuma. He uses government hospitals and has, in his private capacity, often applied his doctor’s skills to save lives.

Motsoaledi has also shown he knows how to spur policymakers into action with an underfunded disease such as tuberculosis. In 2018, he played an important part in getting the United Nations to hold its first-ever high-level meeting on TB, which resulted in a “powerful political declaration to accelerate progress towards End TB targets” to which countries are still being held accountable. (stark contrast to Phaahla)

Along with TB, increased access to HIV medication (six-fold during his tenure as health minister from 2009—2019), and also testing and the HIV prevention pill, are seen as measurable successes of Motsoaledi’s previous tenure. 

But, unfortunately, things are very different when it comes to the state of health systems — these, most experts agree, didn’t improve during his previous decade as health minister. 

Importantly, the success of the NHI relies almost entirely on the improvement of health systems; things like information systems to ensure we have electronic patient files, hospital billing systems, systems to ensure enough health workers are recruited and systems that will ensure we appoint more competent hospital CEOs.  

Motsoaledi’s performance in this regard will be crucial. 

Why long-term solutions will define Motsoaledi’s tenure

To be fair, many of the provincial health crises that happened during his previous tenure played out during a time of state capture. Mark Heywood, executive director of the public law interest organisation, Section27 at the time, told me in a podcast in 2017: “When the Free State is captured by the Guptas, when the Northwest is captured by the Guptas, your ability to see a programme through from conception to a national to a district to a clinic level becomes very, very limited.” 

HOW MOTSOALEDI TURNED AGAINST ZUMA

But state capture or not, the devastating consequences of the lack of proper public health systems during Motsoaledi’s previous tenure, as well as those before him, are still being felt. People such as Babita Deokaran paid with their lives when they tried to stop the corrupt behaviour of irregularly appointed hospital CEOs such as Tembisa Hospital’s (now late) Ashley Mthunzi, who was contracted in 2021 without background checks. 

And although Motsoaledi put systems in place for medical schools to increase the number of doctors they train, many now struggle to find jobs, as the system didn’t also address the accompanying increase in provincial health department budgets that would be required to pay their salaries. 

Motsoaledi’s current tenure will therefore be defined by his ability to develop long-term solutions for complex problems, and this will be shaped by who he employs — which director general, the CEO and board of the NHI Fund — to help him do so.  

Tough love, tough choices

Our health minister will have to make tough choices: there are exceptionally competent national and provincial health department employees, but the opposite is, unfortunately, also true, and, if the many underperforming staff stay on, Motsoaledi’s own performance will be compromised.  

And, ultimately, the minister will need to make sure he doesn’t only ask for opinions, but actually takes the advice he gets. 

Mia Malan is the founder and editor-in-chief of Bhekisisa. She has worked in newsrooms in Johannesburg, Nairobi and Washington, DC, winning more than 30 awards for her radio, print and television work.

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