Looking back to look ahead: Here’s what SA’s former health ombud says

Will the National Health Insurance (NHI) scheme fix South Africa’s unfair health system, a legacy from the transition to democracy 30 years ago when a disjointed structure had to merge to serve a new nation? 

Universal health coverage — which the (current) government wants to achieve with the NHI — is one of the hottest issues parties use in their election speak to garner votes in the run-up to voting day this month, our analysis of parties’ manifestos shows.

But politics and science is a bad mix, says esteemed academic, immunologist and most recently South Africa’s health ombud, Malegapuru Makgoba. 

Over the past three decades he’s seen the confluence — and often conflict — of politics and science, and he’s spoken out against it. To him, the idea that politics has the power to take over scientific thought — as he’s seen during the Aids denialism era — is “a disaster”, he told Mia Malan in an interview in April for Bhekisisa’s monthly TV show, Health Beat.

In the late 1990s and in the first decade of the 2000s, the Mbeki government denied South Africans free HIV treatment because of ill-advised counsel and political agendas. Estimates are that 330,000 lives could have been saved if reason had prevailed. 

Yet we don’t seem to learn. “The dynamics between politics, science and medicine continue,” he says as he reflects on the Life Esidimeni tragedy. His investigation, as health ombud, concluded that a “high-level decision” to terminate the Gauteng health department’s existing contract with the appointed health-care provider was taken “precipitously”, with “disastrous” consequences: 144 people died, 1,418 faced torture, trauma and poor care, and 44 people are still unaccounted for. 

As we gear up to vote later this month, drawing on Makgoba’s experiences and insights helps us understand where things went awry and what can be done better.

Despite having seen many things in the country’s health system going wrong, “I don’t feel that I should lose hope”, he says. 

Here’s more of his insights on what South Africans should expect from the leaders they vote into power — because it can become the difference between life and death.

Mia Malan (Malan): We’ve had six health ministers over the past 30 years. How has that impacted on health policy?

Malegapuru Makgoba (Makgoba): Each one has left a fingerprint in that portfolio. First, we had Nkosazana [Dlamini] Zuma, who set the blueprint for the national health system by amalgamating the different systems from the homelands and the various provinces into a single one. She was followed by Manto Tshabalala-Msimang, who was part of the Aids denialism era, and almost [set] us back in trying to address HIV/Aids by pronouncing funny [treatment] remedies. Then it was, briefly, Barbara Hogan, who terminated Aids denial. Aaron Motsoaledi followed, who, one can say, is largely responsible for promoting the national health insurance (NHI), appointing the national health ombud and promoting the largest antiretroviral programme in the world, [thereby] improving the lifespan of South Africans [with HIV]. He was followed by Zweli Mkhize, who was responsible for appointing the ministerial advisory committee that assisted our country to [deal with] the Covid pandemic, and [now] Joe Phaahla, who has managed to get the NHI [Bill] approved [by parliament]. 

Malan: There have been great things in terms of policy during these ministers’ tenure over the past 30 years, such as tobacco legislation and legalising termination of pregnancy, but there have also been bad things, like the Sarafina scandal and corruption during the Covid pandemic. How does corruption impact our health system?

Makgoba: We put a lot of ideas into how the new health system should be, but it’s in the implementation of those policies that we have failed. [Take] the NHI [as an example]. Everybody accepts that this is the best policy, a transformative policy for the country. But where it gets bogged down is in the debates and the contestation of governance, of how it would impact on taxation, how doctors [would] emigrate from the country if it’s brought into being. 

Malan: What is your take: is the answer to our health problems really fixing our two-tier private and government health system? Can it be implemented in a way that we will benefit from it? Because the argument is generally that it’s going to be rolled out within a system that’s not geared to make it play out efficiently.

Makgoba: However you look at [health care], whether universal or not, it’s expensive, and it has elements that are often not in harmony. I noticed that the minister has said it [universal health coverage, in the form of the NHI] should be implemented in an incremental manner — which is perhaps the best way to do it. Because correcting and transforming a health system that has been entrenched for so long is not like a mathematical formula; you have to do it empirically. You learn as you go. Doing it incrementally and learning from each of the increments would assist us, firstly, to understand what it takes. We know that our tax base is not that big. Implementing the NHI system [will be] a costly business; health [care] everywhere in the world is costly. Let’s get a few centres accredited properly. At the moment, the hospitals [and] the infrastructure, are not really up to scratch to implement such a system. 

Malan: As the health ombud for seven years, until last year, you’ve supervised investigations such as Life Esidimeni or the working conditions at Rahima Moosa Hospital in Joburg. What do investigations like this tell us about the state of our health system?

Makgoba: First, there’s a leadership problem — across the provinces and across many hospitals; there’s a problem of governance, a problem of infrastructure, of staffing and of professionals’ attitudes. So we have multiple problems, which all hamper the health system.

Malan: Do you feel sad when you see these things in the health system? That some of your work could have been taken further? 

Makgoba: Well, I feel sad. But I don’t feel that I should then lose hope. South Africa is my home. Like every South African, I want to live in a country that is successful, that is flourishing. I’m sad that some of the things that I’ve recommended have not been taken forward. But some have — and that I’m happy about. 

Malan: Which things have been taken forward that you’re happy about? 

Makgoba: In the Life Esidimeni example, the government [the Gauteng health department] I think admitted that they had committed what I call human rights violations. She [Qedani Mahlangu, former health MEC] lost her job, and so did the senior level of the department: Dr [TE (Barney)] Selebano, Dr [Makgabo] Manamela, several of the directors. I’m not saying that it’s adequate, but it’s one form of a response to the recommendations. The government admitted that they had dropped the ball on the whole system. 

Malan: You’ve lived through the controversial and difficult HIV denialist period and you were one of the few prominent figures who were willing to speak out and take a stand. What are your memories of that era and what lessons have you learnt from it?

Makgoba: What was really the most disturbing thing for me was that politicians in our country had the guts to think that they can define and determine what medical professions understand as a disease and push through the political power to determine the direction of health. During that period, medical professionals were intimidated — sometimes to not even write the correct diagnosis — because they were afraid of the political consequences. That, to me, was the disaster: that the power of politics was taking over the power of scientific thought.

Malan: Do you think we’ve learnt our lesson that politics shouldn’t drive science? 

Makgoba: No, it continues. It was the same thing in Life Esidimeni … Politics was trying to drive science. The former MEC had received so [much] advice, from the relatives of patients, from experts in the field — psychiatrists — all advising against this project. The dynamics between politics, science and medicine continue.

Malan: If you became South Africa’s health minister tomorrow, what would you do in your first 100 days to fix some of these things? 

Makgoba: First, a disclaimer: I will never be minister of health in our country; I’m allergic to politics. But for argument’s sake, if I became a minister, tomorrow, the first thing I would do is to have a Codesa on health. [Codesa, the Convention for a Democratic South Africa, was a negotiation forum set up to guide South Africa through the transition from apartheid to a new, democratic government.] I would call all the stakeholders relevant to health and say: “We are in a new country, we have a new constitution, based on human rights. How is that reflected in the way we teach medicine, in the way we practice medicine, in the way we provide service in our country? We are transforming South Africa’s health. It’s difficult [to do] in a patchwork manner; you can’t do it that way. You’ve got to get everybody [together] and say: “We’re on a new journey. How do we travel and navigate this together?” I think it can be done. 

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