The shot-caller and the NHI: Can Zweli Mkhize pull this off?

It was mid-morning when the young doctor noticed the tiny girl on a wooden bench in the labour ward, slumped and sobbing.

She was 13, but was only a few inches taller than the hospital table next to her.

Terror flashed through her eyes.

Outside, on a green hill overlooking the uMsunduzi river in the KwaZulu-Natal Midlands, chattering gogos were selling oily amagwinya (vetkoek) and cooldrinks to patients and families who had braved rugged terrain through the early morning hours to reach the health facility.

But the girl with the tear-stained face was alone.

The hospital, Edendale, was about 10km outside Pietermaritzburg, in uMgungundlovu district.

“What’s the problem?” the doctor asked the youngster, kneeling beside her.

She pointed at a protruding tummy that hid her thighs and whispered: “It’s very sore. It’s been like that for a while now.”

The teenager was one of Zweli Mkhize’s patients when he worked as a physician at the hospital in 1986, four years after he had graduated as a medical doctor from the University of Natal.

The physician paused and asked: “Are you pregnant?”

Then the girl, slowly shaking her head from side to side, replied: “I don’t know...”

Mkhize crosses one leg over the other as he sits on a large, black boardroom chair on the top floor of the Durban International Conference Centre. It’s a Tuesday evening in June, just 12 days after he replaced Dr Aaron Motsoaledi as the country’s health minister.

Earlier that day he had opened the 9th South African Aids conference and said:

style="color: #103cc0;">“Between yourselves and the government, we are bound to actively defeat the spread of HIV.”

But tonight, the chanting of protesting HIV activists fighting to end drug stockouts and for better clinics is seeping into the boardroom from the exhibition area below.

Advocates armed with various causes have been demonstrating fiercely throughout the day.

There are almost eight-million people infected with HIV in South Africa, according to health department figures; only about 60% of them are on treatment.

The group that is becoming infected with HIV by far the fastest is teenagers and young women between the ages of 15-24, studies have shown.

And, although Health System Trust data shows this figure has decreased over the past five years, close to 7% of women giving birth in public health facilities are younger than 18. Three-quarters of such pregnancies are unintended, a 2012 household survey published in the journal African Health Sciences found.

Mkhize takes a deep breath and explains: “That girl [in Edendale Hospital] had no idea that she was having labour pains, because she didn’t know she was pregnant and had no one to ask if she was. She received no antenatal care.”

The African Health Sciences survey, which was conducted in the Eastern Cape, Gauteng, KwaZulu-Natal and Mpumalanga, revealed that just over half (55.5%) of female respondents between 18 and 24 got pregnant the first time because they didn’t understand the risks involved in what they were doing or didn’t know how pregnancy happens.

The minister sips lukewarm water from a boardroom glass.

“I had to perform a cesarean section on her and a healthy baby came out,” he says. “But it always hits me: somewhere along the line, a lot of the health challenges we face, including HIV and Aids, have got more to do with the breakdown of families than the individuals you meet in health institutions.”

Mkhize continues: “In a normal family you would expect there to be a mother who will talk to her daughter and explain ‘this is going to happen to your body and so on’. But that pattern of mentorship has been disrupted.

“The problems you encounter in hospitals and clinics are not just outcomes. They’re indicators — of how broken society is, how well our economy is and how well the country’s governed.”

Thirty-three years have passed since Mkhize helped his young patient bring her baby into the world.

Eighteen years after the incident, South Africa became a democracy. Subsequently, the country has had four presidents. State Capture by means of a labyrinth of patronage networks has plundered the public purse to the tune of at least R1.4-trillion. The country’s main electricity provider has all but collapsed, sending the economy into freefall. And the official unemployment rate is approaching 30% with GDP growth having plummeted from 3.5% in 2011 to 0.6% in 2019.

But, during this time, the government also passed one of the world’s most progressive termination-of-pregnancy laws and expanded the public health system’s HIV treatment programme from non-existent to the world’s largest. The availability of antiretroviral drugs (ARVs), which keep people with HIV alive, has led to the country’s institutional maternal mortality rate (women dying while giving birth in public health facilities or soon thereafter) declining by almost a third over the past decade, and life expectancy has increased from 57.7 years in 2013 to 64 in 2017.

Mkhize himself had active roles in all of the above: parts that saw him cast as both hero and villain.

In 1994, at the age of 38, he became KwaZulu-Natal’s first, and the country’s longest-serving, health MEC, his tenure lasting until 2004. Mkhize’s command of the health sector of the province with the highest HIV infection rate in South Africa overlapped with one of the most tragic chapters in the nation’s history: Thabo Mbeki’s HIV denialism that saw the president vehemently opposed to making HIV treatment available, because of unfounded beliefs that ARVs were poisonous. Hundreds of thousands, many of them in KwaZulu-Natal, died as a result.

But the young MEC had the courage to defy Mbeki and to permit at least some of the province’s public health clinics to put HIV-positive patients on ARVs. By April 2004, when the state began to provide free HIV treatment, there were already 11,000 patients in KwaZulu-Natal on the drugs, according to Mkhize’s CV.

However, as an influential member of the ANC’s provincial executive (he was ANC chairperson in Kwazulu-Natal from 2008-2013 and treasurer between 1994 and 1997), and a member of the party’s national executive committee (he became a member in 1990), Mkhize — at least publicly — also toed dangerous political lines.

He formally opposed a court case of the HIV lobby group, the Treatment Action Campaign (TAC), that fought for access to treatment that could help prevent HIV-infected pregnant women from transmitting the virus to their babies. Many, including the then TAC activist Nathan Geffen, who’s now editor of the news service GroundUp, believe this was because Mkhize “could not bring himself to break ranks with Mbeki publicly”.

And, when Mkhize advanced to the rank of KwaZulu-Natal premier in 2009, he did not (again, at least publicly) oppose his then Health MEC Dr Sibongiseni Dlhomo when the provincial minister bought tens of thousands of potentially harmful non-surgical medical male circumcision devices known as Tara KLamps. Although studies had shown that medical circumcision could reduce a man’s chances of contracting HIV through vaginal sex by about 60%, there were serious concerns about the Tara KLamp: it hadn’t received World Health Organisation approval, research showed that men who used it experienced bleeding and injuries to their penises, and, perhaps most importantly, the contraptions had been procured without a tender from a businessman who had strong links to Zulu king Goodwill Zwelithini, who received an expensive car from the merchant around the time the devices were purchased.

It’s been clear long before Mkhize became health minister that the quality of healthcare that someone’s able to access in South Africa is largely dependent on how much the person is able to pay for it. And in a country as starkly unequal as South Africa, and given the current state of the public health system, that means that most people don’t get good healthcare.

Cue the National Health Insurance (NHI) Bill, in the making for the past eight years, that Mkhize released in August. In so doing he achieved his desire to do so within the first 100 days of his reign.

Mkhize is correct when he says South Africa’s [health] indicators reflect how broken society is, how well our economy is and how well the country is governed — and uMgungundlovu isn’t doing well.

If the health minister’s 1986 patient and her baby are still alive, they’d be 46 and 33 respectively.

In 2012 uMgungundlovu became an NHI pilot site, thus receiving huge amounts of additional funding to improve health services there and to prepare the area for the implementation of the scheme.

But, despite the extra money, if the mother and child have remained in uMgungundlovu, not much has changed for them: they’d be living in the district with the highest percentage — 29.7% — of adults with HIV in South Africa, according to a study published in the journal Nature in May.

The chances that either would have completed high school, the district municipality’s demographic data shows, are less than one out of three. Would they have jobs? Not likely; the country’s 2011 Census revealed only about a third of people in uMgungundlovu are employed. In fact, the district health department’s health plan states, 15% of people here survive on less than R400 a month.

And, if the now 33-year-old child was a girl, the possibility that she too would have given birth to a baby as a teenager is high: The Health System Trust’s District Health Barometer (DHS) reveals that 15% of women giving birth in the district’s public health facilities are between the ages of 10 and 19, and only about half of women between the ages of 15 and 49 use a modern form of contraception.

Her likelihood of dying during pregnancy or while giving birth in a public health facility would have been significantly higher than that of the average woman in South Africa: in uMgungundlovu, 170.6 out of every 100,000 live births result in the death of a mother compared to the national average of 105.7, DHS data shows.

But perhaps the most crucial health statistic to highlight in the district, after the release of the NHI Bill, which aims to get wealthier South Africans to subsidise the healthcare of the poor, is: according to its health plan, 85% of uMgungundlovu’s population have no form of health insurance; they’re solely reliant on an underfunded, dilapidated public health system.