His journey started when he was born in 1971 as the son of a domestic worker in Eshowe, in the semi-independent bantustan of KwaZulu. His father worked in supermarkets and grocery wholesalers. His mum’s employers were white doctors. Observing them, he believes, is where his passion for medicine and health was ignited.

Buthelezi wasn’t born with a silver spoon in his mouth, but he did grow up in a time of change and promise. After matriculating from school in Eshowe, from the late 1980s he studied at the University of Natal School of Medicine, and was part of the first class to graduate after South Africa’s 1994 elections.

He was a brand new doctor in a brand new democracy that made everyone’s “right of access to health care services” one of its constitutional promises. The guest speaker at his graduation was one Dr Zwelini Mkhize, an alumni of the same medical school and then MEC for Health in KwaZulu Natal in the first democratic government.

The wheel comes full circle. Today, Zweli Mkhize, who Buthelezi describes as his mentor, is about to be his boss.

I interviewed Buthelezi on Friday 22 May. It was not a good day for the health department. A furore was raging around the statements made by Prof Glenda Gray, into which both the acting DG and the minister had been drawn. Yet, in the midst of a busy schedule of preparatory meetings with the minister, the acting DG, Anban Pillay, and Prof Salim Abdool Karim, Buthelezi had managed to carve out an hour and a half for a free-flowing conversation. He explained that he was also busy wrapping up his job as the chief executive officer of the South African National AIDS Council (SANAC), a position he had held since September 2017.

Buthelezi certainly has impressive credentials for the top job.

We spend more than half an hour talking through his years of experience. His internship was at Edendale hospital in Pietermaritzburg, and he also worked for some time at Emmaus Hospital near Bergville and Manapo Hospital in the Free State. After that, he became medical superintendent at Nkandla Hospital and then at Grey’s Hospital.

So he knows what the frontline looks like and can sympathise with the frustrations of many of our public service doctors.

In fact, he says, it was as a result of this experience that he developed a passion for management: “Working in a hospital I saw the effects of poor management… for example, when I was an intern I worked for four months without a salary.” As a result, he did postgraduate studies at UKZN in health services management and then a bachelor’s degree in management at the Durban University of Technology. It left a lasting impression and today he thinks “we need to change the way we train doctors and include management as a part of training”.

But in March 2000, his career took a turn from being a doctor to a manager.

Buthelezi was appointed as the first director of the KZN HIV, AIDS and STI programme, a position that involved establishing HIV coordinators in all districts and setting up the prevention of mother to child HIV transmission programme.

We didn’t dwell on it, but the position must have been politically complicated.

By this time KZN had become the epicentre of the HIV epidemic. Zweli Mkhize was still the MEC for Health, although balancing between a presidentially inspired AIDS denialism (which he later said he disagreed with), and Lionel Mtshali, a premier from the IFP, who denounced it. In the famous court case brought by the Treatment Action Campaign (TAC), KZN rebelled against the dictates of then Health Minister Manto Tshabalala-Msimang, but when the IFP lost KZN to the ANC in the 2004 general election, it once more fell into line.

But Buthelezi must have done well because four years later he was promoted to the position of regional chief director, responsible now for all health services in five mainly rural districts. A couple of years after that he became general manager of strategic programmes in the KZN department of health, including in his remit HIV, TB, maternal health and even a dose of XDR TB during an alarming outbreak at Grey’s Hospital in 2010.

Buthelezi himself says SANAC was a challenge that he only partially succeeded with. He feels he played a positive role in governance, managing donor relationships and steering the midterm review of the 2017-2022 national strategic plan on HIV, TB and STIs, a report on which is due to be released soon.

Around this time, something went wrong and Buthelezi fell out of favour. There were controversies, such as over the use of the Tara Klamp, an unsafe medical device for male circumcision, a matter that the TAC referred to both the Human Rights Commission and the Public Protector. 

“A lot of reservations about the use of the device were raised by clinicians and we opted for the dual approach to allow clinicians to have options that suited their clinical skills,” says Buthelezi.

There was also an allegation of his involvement in corruption in the awarding of a tender, but internal charges were later withdrawn.

A souring of relationships was “the main reason” why, in 2010, he took up a new job as the director of programmes at the Columbia University-based International Centre for AIDS Care and Treatment Programmes (more commonly known as ICAP.)

In his role at ICAP, and also later as an independent health consultant, Buthelezi acquired another field of experience and exposure that provided vital learning for his job as DG.

He told me that, among many other things, this involved work on primary health care re-engineering (PHC); helping to establish the Office of Health Standards Compliance (OHSC); and later the SA Health Products Regulatory Authority (successor to the MCC); as well as the restructuring of the SA National AIDS Council (SANAC). It involved him in the health systems of other African countries and saw him managing large donor grants.

Finally, in September 2017, he replaced Dr Fareed Abdullah as the CEO of SANAC, a position he has held until today. According to Abba Omar, the chair of the SANAC Trust, Buthelezi was “extremely good and on top of his game”. He was “keen on good governance, worked well with the Board and the Global Fund to Fight AIDS, TB and Malaria (GFATM)… I was amazed at his level of energy.”

Anele Yawa, the General Secretary of the TAC, was a little more circumspect.

“We have been working to cement our working relations with him as the CEO of SANAC, as much as he is not perfect, but we worked very well with him and we hope that these working relations will continue. The appointment of Dr Buthelezi as the DG of health came at a critical moment. He has committed that he is going to work with the PLHIV sector and support the community led monitoring conducted by the PLHIV sector. We have agreed that we are going to convene another meeting with him as the newly appointed DG where we are going to table the challenges that our healthcare system is still faced with.”

The DG is the accounting officer – there is a clear delineation between them. His job is to ensure prudence in the management of finances and “you need a cordial, respectful working relationship”.

Buthelezi himself says SANAC was a challenge that he only partially succeeded with. He feels he played a positive role in governance, managing donor relationships and steering the midterm review of the 2017-2022 national strategic plan on HIV, TB and STIs, a report on which is due to be released soon.

These are all important, I agree, but what actual outcomes did you bring about?

“I tried to stabilize SANAC, there was disruption and infighting.” He argues that SANAC must “stabilise the governance of its civil society component because otherwise this might break SANAC and affect its credibility.” 

Nonetheless, he states that he has had “a good working relationship with the PLHIV sector [a group of organisations of people living with HIV]… they need to be in the front because the fact of the matter is that we are dealing with HIV”.

Which just about brings us back to where we are today.

Transparency, accountability and public service

By all accounts, Buthelezi is a man well qualified for the top job. He’s the fifth DG of health in the democratic era, following in the shoes of Olive Shisana (1994-1998), Ayanda Ntsaluba (1998-2003, Thami Mseleku (2004-2009) and Precious Matsoso (2009-2019). It’s never been an easy job and it’s sometimes been controversial, with DGs often ending up at odds with their ministers. Now, the job is about to get a lot harder.

Buthelezi takes office in the middle of the Covid-19 crisis. Although the National Health Insurance Bill, the biggest and most disputed health reform of the last 30 years, has been temporarily displaced as a cause of conflict, its future now sits squarely in his lap. 

The national department of health is also seriously depleted of its senior management team. On the day that he arrives, Dr Yogan Pillay, a long term survivor of various health ministers, leaves as deputy director-general for communicable and non-communicable diseases, a vast portfolio. Pillay has been in the department for 23 years and, whatever you may think of his track record, his institutional memory and knowledge of South Africa’s health sector is considerable. Buthelezi needs a team and he needs it fast.

So, great CV and experience aside, I am compelled to ask him a few hard questions. First, I ask about his relationship with Mkhize. If he doesn’t think it’s too close.

He says: “I understand Mkhize very well, he nurtured me. I adore the way he works. You need to understand the politics of your boss; if it was another minister I might not have applied. 

But, I wonder aloud, whether such a close relationship with your political principal isn’t a danger? Buthelezi thinks not. 

“You need to protect your boss [but] I won’t take what the minister says as the true gospel. We are not short of skills.” 

The DG is the accounting officer – there is a clear delineation between them. His job is to ensure prudence in the management of finances and “you need a cordial, respectful working relationship”.

“If I don’t agree with my boss I will explain why, offer a different way and not make it personal.”

I ask whether he would have handled the Glenda Gray controversy differently, but he bats it away. “The MAC has clear terms of reference and you always have a human element.” I’m not sure what that means, but we leave it at that.

Next, I ask him about smallanyana skeletons and whether he has any?

He’s very frank. He acknowledges the corruption allegations against him in 2009, but says anyone can “confirm with doctor Sibongiseni Dhlomo (previously the KZN MEC for health, now the chair of the health portfolio committee in parliament) that it was resolved and that we continued to work cordially thereafter”.

I ask whether he would have handled the Glenda Gray controversy differently, but he bats it away. “The MAC has clear terms of reference and you always have a human element.” I’m not sure what that means, but we leave it at that.

This is a stigma that has hung over Buthelezi for a while. It was even raised in the NCOP at the time of his appointment as CEO of SANAC. In response to questions from the EFF, Cyril Ramaphosa, then deputy president, told the NCOP that, “We will examine all the details that you have put forward and I will discuss it with the trustees of the SANAC Trust and we will then take the matter forward.”

Abba Omar, chairperson of the SANAC Trust, tells me that when Buthelezi became SANAC CEO, all his private interests (see below) were declared to the company secretary. He acts above board.

Buthelezi is forthright. He says corruption is a “disease eating government resources”. 

“Health is commodity-heavy and thus a breeding ground for corruption. We need to have proper consequence management.” He points to the problem the health department has had of exercising control over corruption in the provinces, and links it to the way health services are listed as an area of concurrent national and provincial competence in  the Constitution. “We need to rethink, but I don’t know how.”

I ask him if he would volunteer for a lifestyle audit, as promised (but still not delivered) by President Ramaphosa?

“With ease,” he responds. “I am happy to disclose what I have in terms of property and cars.” 

“You are paid from the public purse” and therefore such audits “should be standard in the public service and not only for senior officials.”

I push a little further. Does he have any private business interests?

Again a frank response: “Yes, but I’ve declared them and I’m pulling out of them.” He mentions two in particular, Zibuyile Healthcare Mpumalanga and Kusile Madoda Investments, but says he has “got my lawyer to deregister me” and that “nothing I’m involved in involves tendering”.

Further research on the CIPC database reveals that he’s also listed as a director of Ekuphileni Nkomazi Hospital (a company listed as still active) and six other companies. But, one trusts, this was declared in his application for the position.

Finally, I ask how he feels about starting his tenure in the middle of the worst health crisis of a century – a job he applied for before it was clear just what Covid-19 had in store.

Buthelezi provides a long, considered answer. He says he sees both the negative effects and positive possibilities arising from the pandemic.

On the downside, there’s the disruption of HIV and TB services, and here he cites reports that 11,000 people in Gauteng have not collected their ARVs: “If we don’t respond aggressively we are going to lose the ground we have made.” He says there’s a need to integrate TB and HIV screening into Covid-19 screening, and the GFATM has provided R66-million for this purpose. “After all, half of the symptoms are the same.”

On the upside, he refers to the very good collaboration between the public and private sectors over Covid-19, the releasing of funds to fill vacant positions in hospitals – “but how do we sustain that?” – and the fact that “never in the history of our country have healthcare workers been recognised like now. We must not lose that. They are the darlings of everyone now and that’s good for motivation”.

He sees the crisis as providing “fertile ground” for the next steps on NHI. In this context, I pop in a question about the recommendations of the Health Market Inquiry (HMI) into the private health market. He says “it’s very important for consumers… it came at the right time. I’m a doctor and I’ve been on a medical aid all my life and I don’t understand the options”. For this reason, Buthelezi thinks the proposal for a regulatory body is important.

Health is a big subject and we could have gone on. But time was up. And so into the Covid-19 storm, he goes. I wish him well. 

Precious Matsoso, the last DG, brought dignity and stability to the position. She was honest, accessible and open. But that wasn’t enough to stop a series of crises, including Life Esidimeni and the mushrooming of endemic corruption in the department. You have to be made of stern, incorruptible stuff for this job.

Let’s hope Buthelezi is. Millions of lives depend on it. DM/MC