“Oh no, no! I have never applied or aspired to be Director-General,” laughs Yogan Pillay. “That is a terrible job. You have to deal with all the politics. It is a thankless job and you are always getting bashed. I prefer to stay with the technical work.”

One of the most effective post-apartheid public servants, Pillay recently left the national Department of Health after 23 years’ service. At the time of his departure, he was the Deputy Director-General responsible for three massive departments – infectious diseases, including HIV and tuberculosis; maternal and child health, and non-communicable diseases, including mental health. 

Despite rumours, Pillay assures me that there’s nothing ominous about his departure. He didn’t want to be DG and he had decided to leave months before Covid-19. 

He simply wanted a global challenge, but didn’t want to leave the country because of his 13-year-old son, Vishay. Without a day’s break, he joined  the Clinton Health Access Initiative (CHAI) in June 2020 as it’s country representative and global advisor on universal health coverage. CHAI helps countries to access cheaper medicine and treatment.

Pillay qualified as a psychologist and worked as a university lecturer before moving into health management and getting a PhD in health policy and management from Johns Hopkins University in the US.

Perennially youthful, Pillay says he sticks to a largely vegetarian diet, runs, gyms and mainly avoided the many banquets that top officials are invited to.

He had his first stint at the health department in 1996, where he worked on the district health system for three years before heading the USAID-funded Equity Project that also focused on districts.

In 2003, then DG Ayanda Ntsaluba brought him back into the department as chief director of strategic planning. The terrain was difficult. Controversial Manto Tshabalala-Msimang was health minister, President Thabo Mbeki believed antiretroviral medicine was poisonous and HIV was a battleground.

“My salvation was that I was not involved in the HIV programme at the time,” says Pillay. 

Five years later, when Tshabalala-Msimang was removed, Pillay accepted the position of chief director for HIV and TB, and helped to steer the country out of the disastrous period of Aids denialism.

Pillay is proudest of three things during his departmental career: the improved access to antiretroviral (ARVs) medicine, which resulted in a substantial increase in life expectancy; reducing maternal, baby and child deaths; and reducing the transmission of HIV from mothers to babies.

“Antiretroviral coverage was around 350,000 in 2008 and it’s now over five million,” says Pillay.

In 2009, men lived until 55 and women until 58. A decade later, male life expectancy is 62 and females’ is 68 – in large part thanks to easy access to ARVs.

Less than 1% of mothers with HIV – around 0.74% – transmit the virus to their babies in comparison to over 6% in 2009.

Maternal mortality is defined by the deaths of women while pregnant or within 42 days of pregnancy. In 2019, there were 978 deaths – “the first time since 2002 that maternal deaths have fallen below 1,000”, says Pillay.

Those are his headline achievements, but there are many others. When Aaron Motsoaledi became health minister, he and Pillay tackled tuberculosis, long neglected as a “disease of the poor”. They introduced Genexpert machines to speed up testing for drug-resistant TB and made a far less toxic medicine for drug-resistant TB, bedaquiline, available in public health – both world firsts. The Genexpert machines are currently being used to test for Covid-19.

When Mel Freeman, the chief director of NCDs, retired a few years back, his portfolio was also added to Pillay’s plate.

“There was a sense that the progress we made in HIV and lessons learnt could be applied elsewhere,” explains Pillay, who believes that people can only be healthy if their environments enable this.

“While individual responsibility is important, you can’t only focus on the individual and expect them to change unless their environment is more supportive.” 

He uses the example of food: “In the past 18 months, the department started to engage with the food and beverage industry to get them to change what’s in their food, and drink. To cut down the sugar, salt and fat, to change their menus and how they advertise.” 

Fiscal federalism

But there are also structural stumbling blocks that prevent effective health service delivery. Constitutionally, the national and provincial health departments have concurrent responsibility for health. The national health department develops policy and monitors its implementation, which is done by provinces. Yet corruption thrives in many provinces and millions of rands that should have gone to healthcare have been misappropriated.

“What changed the trajectory of transforming the health system was the introduction of fiscal federalism in 1999-2000, where provinces got an equitable share of the budget and could decide what they should fund,” says Pillay. 

To protect HIV budgets, Treasury issued conditional grants with tightly ring-fenced requirements to provinces rather than leaving delivery to provincial discretion.

Conditional grants have since also been issued for malaria, mental health, the HPV vaccine and cancer. But this hasn’t solved service delivery problems. 

“The hiring of staff also changed. There used to be national norms about how many positions each province should have. In 2001/02, this also changed when MECs became executive authorities over hiring and firing of staff, and it resulted in a number of unintended consequences. We’ve got more managers now in the health sector than we have ever had. The key question is: has this improved the quality of services?”

Pillay answers his own question with characteristic diplomacy: “In some areas, possibly, in others possibly not.”

In most provinces, this has been a disaster. MECs have tended to appoint their political connections and their head offices are bloated, leaving less money to employ health workers.

Decentralised service delivery

Pillay acknowledges that there are problems with the delivery of health services at clinics and hospitals.

“There is a limit to the progress we could make with programmes [such as HIV and TB] without robust service delivery at primary level and hospitals. My regret is that we didn’t have enough traction with service delivery. I was trying to get the programmatic areas to be linked with a service delivery platform at primary healthcare level.”

Pillay believes that the National Health Insurance (NHI) scheme could address this.

“We can’t continue having small pockets of money and think we can move the needle significantly. The only way to change things is to set up the NHI. People tend to see the NHI merely as a funding mechanism, but it is much more. The idea is that, when the NHI Fund is set up, these conditional grants will go into the fund. But delivery must be decentralised, with fairly significant decentralised authority.”

Under the NHI, hospitals are due to have much more authority. They are supposed to be allocated funds according to their performance in key areas, which will be monitored by the independent Health Standards Authority. Well functioning hospitals and clinics that reach patient targets will be rewarded with bigger budgets.

Open-door policy

Colleagues, activists, doctors and academics have all praised Pillay’s dedication and open-door policy – although with some caveats.

Francois Venter, one of the country’s foremost HIV clinicians, describes Pillay as “a refreshing straight-talker in a sea of HIV rhetoric and platitudes”.

“We had lots of disagreements about health programmes, but he was always willing to listen. He had one of the most extensive portfolios I have ever seen. He cared deeply for the health system and had the deepest integrity. However, he needs to be dragged kicking and screaming into the 21st century and lose the paper diary,” said Venter, who heads Ezintsha at the health sciences faculty at the University of the Witwatersrand.

Professor Helen Rees, Executive Director of the Wits Reproductive Health and HIV Institute, praised his “no-nonsense style, go-to reputation and sharp, strategic thinking”.

“A lot of our conversations would be typified by Friday evening drive-home work calls when one of us needed something from the other one. Without fail, he would always answer your phone and in a somewhat resigned tone, but always with humour say: ‘Hello Helen.’ I hope that he continues to pick up the phone on a Friday as you assume your new role!”

Ashraf Coovadia, head of paediatrics at Rahima Moosa Mother and Child Hospital, describes Pillay as “one of the most committed and dedicated public servants”. 

“He avoids politics and deals with the substance of issues. I would say that he is a non-political technocrat who is interested in what is happening on the ground. He doesn’t get involved in personal attacks. You would never find him being vindictive.”

Popo Maja, the health department’s director of communications, says Pillay is “an unsung hero of public health here and abroad”. 

“Very few people have the understanding of public health that he does. His reasoning and contribution to discussions about public health policies have been inspiring to me personally. Yogan is one of those fine intellectuals in the health sector who understands the morality of NHI and ‘Health for All’.”

Should he have spoken up?

Anele Yawa, president of the Treatment Action Campaign (TAC), said that although his organisation did not always agree with Pillay, “he never shut his door to us”. 

“During his tenure, the number of people on ART exponentially rose, culminating in Universal Test and Treat. Under his and his colleagues’ leadership, life expectancy also rose. We celebrate this particularly given the dark days we have seen,” said Yawa.

Praising his dedication, Yawa said Pillay had assisted activists on a number of occasions. In 2019, he “woke up in the dead of night” and went to a Durban health facility that had failed to treat TAC members to ensure that they received medical attention.

But Yawa said that the fact that Pillay had been in the department during Tshabala-Msimang’s reign “brings into focus the role of a departmental official in fulfilling their mandate towards patients versus their role in relation to their superiors. We strongly believe more could have been done by Dr Pillay and others.”

Activist Mark Heywood had similar reservations. Heywood praised Pillay for being “hard-working and a largely accessible public servant over a very long time”. 

“He has worked through all five of South Africa’s health ministers (and DGs) and been loyal and dependable to each one of them. 

“That may be both his greatest strength and weakness. Because Yogan Pillay probably knows better than anyone else the damage that politics and corruption, and cadre deployment have caused to the health system and the lives that have been lost as a result,” said Heywood.

Perhaps Pillay’s secret power was that he tried to fix the holes in the system by keeping his head below the parapet and devising technical solutions – like conditional grants – to outlast and outwit venal politicians and protect patients.

“He has chosen never to speak out about it publicly. In a private conversation, he will occasionally open up and admit that civil society criticism and insights have truth. But then he will go back to being the loyal public servant. Perhaps one day Yogan himself will explain his reasons and offer a justification.”

This is a tricky requirement. If Pillay had spoken out publicly, would this have improved the problems in the provinces or simply resulted in him being isolated and powerless?

The health department has never taken kindly to government officials’ speaking out in public. 

In 2019, former DG Precious Matsoso was chastised for intimating that the health department had been sidelined by the Presidency in the NHI process.

Last week, Professor Ebrahim Variava, the head of internal medicine at Tshepong Hospital in Klerksdorp in the North West, was suspended for vague reasons amid speculation that he was being punished for warning that the province wasn’t ready for Covid-19.

Perhaps Pillay’s secret power was that he tried to fix the holes in the system by keeping his head below the parapet and devising technical solutions – like conditional grants – to outlast and outwit venal politicians and protect patients.

It is possible that Pillay was in such an unassailable position that he could have spoken out against corruption and other systemic cancers without risk. But it would have been a gamble that was out of character for Pillay.

Whatever the case, I am sad that Pillay is no longer there; that he will no longer contact me after I have written stories and tweets about health service delivery problems to ask for more details so that he can try to sort them out. DM/MC

Kerry Cullinan is health editor for openDemocracy.