Can Motsoaledi pull off NHI?

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

And why was Phaahla, 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 DA’s Leon Schreiber? 

We can throw a lot of arguments around about Motsoaledi’s and Phaahla’s respective seniority in the ANC, their levels of support for 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 No 27 to Phaahla’s No 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 election. 

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 & 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 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.

The ANC has fought tooth and nail, also in the provinces, to keep health ministries under its rule; and it has succeeded in all provinces but the Western Cape, which is governed 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-decade-long work history? 

And Phaahla and Motsoaledi, 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 60s, hail from Limpopo, studied medicine at the University of Natal during the late 1970s and early 1980s, and, as senior ANC leaders took an exceptionally strong, public stance against state capture in 2016 and 2017 — while they were, respectively, also health minister (Motsoaledi) and deputy health minister (Phaahla) — by supporting motions of no confidence against the ANC’s former leader Jacob Zuma.

Neither Motsoaledi nor Phaahla is associated with incidents of personal corruption and both are strong allies of Ramaphosa. 

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

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

In 1997, after both had served as MECs for three years in Limpopo’s first democratic government, then premier Ngoako Ramatlhodi axed Motsoaledi as education MEC and replaced him with Phaahla (who was health & 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, after former health minister Zweli Mkhize resigned because of corruption allegations and while Motsoaledi was home affairs minister. 

For eight of Motsoaledi’s 10 years as health minister between 2009 and 2019, Phaahla served as his deputy, as he is now again. 

Will the GNU allow the rollout of 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 DA, will be facing a particular dilemma, as its own health policy is based on expanding access to medical schemes — in stark contrast to the act, which says medical aids have to be scaled down to provide only services not covered by NHI, so that money paid towards private health insurance could instead be used to pay for NHI.

The act, which has been assented to but not yet 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 though 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 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 for 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 National Treasury to allocate him a sufficient budget to cover the cost of rolling out the scheme — or it will never get off the ground. That could be anything between R200m and R500m a year, depending on whose predictive calculations you use. Essentially, nobody knows the cost, because it’s unclear which services the NHI would provide.

And, 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 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 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 TB. In 2018, he played an important part in getting the UN 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.

Along with TB, increased access to HIV medication (six-fold during his tenure as health minister from 2009 to 2019), testing and the HIV prevention pill is seen as a measurable success 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 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 North West 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.” 

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 though 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.

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