Interview with Minister Aaron Motsoaledi, Minister of Health

Part 1

Amandla!: How did you became politicised?

Aaron Motsoaledi: I was born into a family of activists. Elias Motsoaledi, one of the Rivonia trialists, is my uncle. I became active in boarding school during the Soweto uprising in 1976. What the Soweto students were striking for affected me directly. I was in a school where they were forcing us to learn in Afrikaans – it was a nightmare. I was doing mathematics in Afrikaans and I did not understand it at all. This immediately lit fires in me to join up. And unfortunately that very same day the police invaded our campus.

A!: Why does the nation’s health mean so much to you?

AM: Because it is part and parcel of a better life. If we want to change the stan-dard of living of South Africans, the two main areas we should change are education and health. The rest will follow – including, by the way, job creation and reducing crime.

A!: Do you and your family use the public health system?

AM: Oh, yes, we use the public health system. In Cape Town I use Groote Schuur Hospital, and I send my kids to the provincial hospital in Polokwane.

A!: What are some of the shortcomings of the public system?

AM: Some of the best doctors and specialists in this country are in public hospi-tals but because of the way we manage them, they look like they are mediocre. When people step into a private hospital they believe they’ve got the best and the wisest doctors there, but this is not necessarily true, because where are the professors?

There are four outcomes we must achieve in turning around the public health service.

First, increase life expectancy, and I am happy because recent reports show that life expectancy is improving. Second, reduce maternal and child mortality. Third, reduce the burden of disease caused by TB and HIV/Aids. Finally, improve the effectiveness of the healthcare system. And by healthcare system I mean both public and private – the whole healthcare system is not effective.

In preparation for NHI we expect massive improvements in the public sector.

Firstly, we have identified infrastructure that has not been maintained.

Second is human resources: planning, development and management. How many nurses do we need? How many doctors, physiotherapists, pharmacists? Who pays them? How long should training take? Who can become a CEO of a hospital, at what level? What should be their qualifications and years of experi-ence? Where should they get training? We are going to spend billions to refur-bish nursing colleges.

Thirdly, improving the quality of care. What do we mean by ‘quality’? We identify six clear elements that members of the public will identify with: cleanliness, safety and security, staff attitudes, infection control, long queues and waiting times, and drug stock-outs where medicines run out even when the budget is there.

We need a special office to deal with these issues, so it’s not something sporadi-cally done by a minister when somebody complains. We call it the Office of Health Standards Compliance (OHSC), equivalent to the Quality Care Commis-sion in Britain, a special commission that checks quality in all the public hospitals.

It will have three units. There will be an inspection unit that will arrive unan-nounced to check and report on compliance. Problematic hospitals will have fre-quent visits, others maybe every four years. Secondly, there will be an ombuds-person to whom dissatisfied members of the public can complain. Lastly, a certification office will certify every health facility that is up to standard.

The fourth big thing is re-engineering primary health care (PHC) the core of the National Health Insurance. PHC means moving away from our curative health-care system towards programmes that prevent diseases and promote health. We must reduce people’s vulnerability to diseases so that fewer need the healthcare system. The burden of disease is huge in South Africa.

Re-engineering PHC involves three streams. Firstly, each district, especially rural ones, must have a team of seven specialists to deal with clinical problems. The second stream is municipal ward-based primary care delivered by outreach teams with a professional nurse, staff nurse and community health workers. And third is a school health system, to care for the 12 million kids at school through health promotion and disease prevention.

To encourage private doctors to participate I have asked GPs in all the pilot dis-tricts to choose a clinic where they will go once or twice a week and provide four hours of service – we will pay them. Patients must know that they are likely to see this GP at the clinic who has a practice around the corner that they can’t af-ford to visit.

A!: In what way is the private system dysfunctional?

AM: The main problem is unsustainable prices. It’s not cost-effective, it’s not value for money. Even people who call themselves middle class can’t afford it. It has priced itself out of reach.

A!: Who do you think will be the big losers?

AM: There should be no losers. Every citizen must have access to a good quality healthcare system if and when they need it, irrespective of financial circum-stances. Why should you lose when everybody else is winning? If you think you are losing you are greedy — the country can do without you.

There are two preconditions for NHI to work: public hospitals must work, and pricing in private healthcare must be controlled, even if this needs a pricing commission. So I don’t know who’s going to get enriched. That’s not the aim of NHI. The aim of NHI is to afford access to good quality healthcare for all irrespective of socio-economic conditions.

A!: What role will remain for private health?

AM: They have a big role. People need to be able to use both systems if neces-sary. We can’t afford a fragmented system. In the past we had 14 healthcare sys-tems. We abolished them through the Constitution. Eighteen years later we have two systems – private for the rich and public for the poor. We can’t afford that.

Three conditions prevent good health outcomes: hospital centrism (promoting curative care rather than prevention and health promotion), fragmentation (in-cluding between public and private), and uncontrolled commercialism (that’s where tendertreneurs come in). The American system is extremely expensive because there’s uncontrolled commercialism. But the South African healthcare system has all three.

A!: So once the NHI provides quality public healthcare, why would any South African ever visit a private facility?

AM: There will always be people who want private care and we won’t stop them. We are not necessarily going to abolish medical aid. Elsewhere I’ve seen private hospitals say, look, I’ve got 100 beds; I’ll charge 30% of them on the NHI and leave 70% to those who are prepared to pay for their own private corner alone, with TVs and everything. But the NHI shouldn’t pay for this.

A!: Are you seeing the impact of factionalism in the health system?

AM: The impact is mostly from tenderpreneurs. In Limpopo, which is the worst of them all, in Gauteng, which is working hard to get out of it, and in the Eastern Cape, what we’re facing is not factionalism but tenderpreneurs – people who want to eat from the healthcare system via tenders. Health must come before tenders. Currently the tenderer gains while healthcare suffers. In Gauteng and Limpopo, tenderpreneurs got millions while the health system was on its knees. That’s why I’m fighting it.

A!: Much of the burden of primary health care falls on community members and relatives, mostly unemployed women. Do you envisage paying home-based caregivers a living wage in the NHI?

AM: The municipal ward-based PHC system includes everybody – we are undoing fragmentation that took place over years. We have home-based care workers, CDWs, TB DOTS supporters, HIV/Aids lay-counsellors — we’ll bring them together into one primary healthcare team.

Some are employed by the Department of Social Development, others by Health, NGOs – we want to do away with that. In KZN they already have put people from disparate locations together under one team. They have a concept meaning ‘Wake up and build’. And that type of model is just something that is out of this world.