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Yogan Pillay is at home in his shorts — as well as on the global stage, leading HIV and TB delivery for the Bill & Melinda Gates Foundation. Picture: Sean Christie
Yogan Pillay is at home in his shorts — as well as on the global stage, leading HIV and TB delivery for the Bill & Melinda Gates Foundation. Picture: Sean Christie

An HIV doctor working for an NGO 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 target (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 the 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 recalls.

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 living 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 pair of 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.

“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 says he feels sorry for me.

Pillay racing the Om die dam Hartbeespoort half-marathon in 2003. Picture: Supplied
Pillay racing the Om die dam Hartbeespoort half-marathon in 2003. Picture: Supplied

“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 insists he will be the exception.

But I had already talked to enough people in South African health-care 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.

Pillay co-authored two textbooks on global health, co-edited books on mental health and on the South African health system and wrote dozens of peer-reviewed journal articles. Picture: Supplied
Pillay co-authored two textbooks on global health, co-edited books on mental health and on the South African health system and wrote dozens of peer-reviewed journal articles. Picture: Supplied

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 and, later, to Pietermaritzburg when his father was appointed headmaster of a school there. 

Pillay matriculated from Raisethorpe High School in Pietermaritzburg in 1975. Here he receives the prize for the second-best academic student in his class. Picture: Supplied
Pillay matriculated from Raisethorpe High School in Pietermaritzburg in 1975. Here he receives the prize for the second-best academic student in his class. Picture: Supplied

After matriculating, Pillay applied to study medicine at Wits University 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 Joburg. My dad got one of my cousins to drive me up, and we started looking for accommodation.” 

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.

He dropped out after a year, enrolling instead for a BSc at the University of Durban-Westville, eventually ending up at the University of Natal’s clinical psychology programme.

There he completed an honours and 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, and Pillay 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, finishing his PhD in 1995 and returning home.

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. Picture: Supplied
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. Picture: Supplied

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

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

After three years a US-based NGO offered Pillay the reins of a project to strengthen primary health care 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, later taking the job of chief director for strategic planning in the national department and then deputy director-general (DDG) for health programmes. 

In that vast role, which he held from September 2008 to May 2020, he oversaw the HIV/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 5-million. Between 2008 and 2018, life expectancy in South Africa increased by 10 years.

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 health-care 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 recalls 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. The Western Cape did it, and KwaZulu-Natal did it, but generally speaking the provincial MECs [for health] were scared,” says Pillay.

A changing of the guard

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

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

“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.” 

One of the awards Pillay received over the years was from the KNCV Tuberculosis Foundation for his work in combating TB. Picture: Supplied
One of the awards Pillay received over the years was from the KNCV Tuberculosis Foundation for his work in combating TB. Picture: Supplied

On a structural level, the idea was that HIV treatment should become a primary health-care 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”. 

That year he 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.

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. Picture: Delwyn Verasamy
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. Picture: Delwyn Verasamy

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

“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.

Pillay is not the first senior health department figure to have joined a major international player, but it is a career move that raises eyebrows.

Speaking on condition of anonymity, a senior policymaker in government tells Bhekisisa: “Health planning has never been politically innocent or ideologically naive. 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.

“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,” he says.

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

Pillay has been working with the department and the US President’s Emergency Plan for Aids Relief (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 target.

“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, the importance of 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 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.”

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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