Last week on a busy day of meetings, newly minted Minister of Health Dr Joe Phaahla sat down to talk about his priorities and approach to what must be the most difficult ministry in government. In the middle of Covid-19, corruption allegations about his predecessor and the murder of health department whistle-blower Babita Deokoran, the minister had plenty on his mind.

Phaahla’s CV attests to the fact that he is no stranger to government or health. He’s been a health activist for 40 years, since he left school in 1976, a deputy minister since 2009 and the deputy minister of health from May 2014, first in the shadow of Dr Aaron Motsoaledi and later under Dr Zweli Mkhize.

Now, with about 30 months to go to national elections in 2024, he finally gets to take hold of the reins and his chance to shine as a minister. But will he?

Phaahla says the most immediate challenges are of course the ongoing Covid-19 crisis and the roll-out of the vaccination programme. Phaahla said his objective was still to have up to 60% of people vaccinated by the end of the year. But rather than focus on the Covid crisis, which takes most of our attention, I wanted Phaahla to talk about pre-existing health challenges that have been eclipsed by Covid-19, but have not gone away.

In fact, there is mounting evidence that many have got worse. We carry the full interview below, but the headline issues that came from the interview can be summarised as follows:

• His growing concerns about a mental health epidemic as a result of Covid-19, especially among health workers;
• His intention to start a process to implement the recommendations of the Competition Commission’s Health Market Inquiry into the private healthcare sector;
• His desire to build on the constructive working relationship with the private sector that has been achieved under Covid-19;
• His worry about the capacity and skills-mix of the national department of health, together with continued concerns about provincial governance of health, which he says “needs the attention of the highest level of government”;
• His concerns about managing the fallout when key members of the national leadership team are suspended as disciplinary inquiries are conducted into findings of the Special Investigating Unit’s (SIU) probe into corruption linked to the Digital Vibes contract. Maverick Citizen has since the interview learnt that the suspension of a number of senior implicated parties is imminent.

Because many people will be interested in the details of health policy and the minister’s approach and plans, we publish an edited transcript of the full interview below.

Mark Heywood: Can you talk about your vision as the Minister of Health picking up in the middle of the Covid-19 pandemic. We have heard at a national level about the economic recovery plan, but there is also a massive job around the recovery of the health system and recovery of setbacks around other health areas. I would like you to sketch out your vision — and say whether it’s a vision of continuity with your predecessors or if there’s anything that you would like to do differently?

Dr Phaahla: Firstly, let me just say that my appointment as minister is a continuation of the sixth administration led by the African National Congress (ANC). We are all familiar with the fact that we operate within a particular constitutional architecture where it is parties which contest for elections based on their manifestos, and a party that wins for that term has an opportunity to implement its policies and manifesto.

Now we have got an overall policy framework of the ANC which is underpinned by the Freedom Charter and ANC conference resolutions. The ANC won the 2019 elections based on that manifesto and so I come in the middle of that — in the implementation of that manifesto and within the broad framework of the ANC policy.

So from that point of view — from that context, there’s clearly continuity. But within the context in which you implement the overall manifesto and policy guidance of the party there are specific realities, objectives and subjective conditions.

One of the objective conditions of today is that whatever we do, the Covid-19 pandemic is dominating — in terms of implementation of your overall policy programmes. So what we would have said prior to 2019 still remains.

But then as you implement those policies, you have to do that within the context of the pandemic.

My immediate focus is how to contain the pandemic; how to stabilise the situation in terms of the measures which we have taken to make sure that our health facilities are able to manage the repercussions of severe illness, admission to hospital, to ICU and all that, as a result of the Covid-19 pandemic.

But also the prevention measures — non-pharmaceutical interventions, leading in government and in society in promotion of those.

But now that, since the beginning of 2020, we also have a biomedical intervention which is vaccinations, how do we drive that? So that’s really in terms of the containment of the pandemic.

I look at this not as a short-term challenge but as a fairly medium term. I’m not an epidemiologist but from all discussions it’s clear that we’re not in this for the short term. It’s medium term — [Covid is going to be within us] for another four or five years. So, how do we contain it and bring down the pressure on the health services, society and economy to a level where there can be reasonable activity in the economy and society?

That’s really on the pandemic side. Then beyond the pandemic, we need to strengthen our health services platform — the pandemic does create complications for all the things that we wanted to do, from the improvement of services at the primary healthcare level to the secondary, tertiary healthcare level and so on.

Prevention of disease, early detection and making sure that people have access, from the very low level of need up to the highest level and then improving the quality — so that’s truly the second leg.

My final leg is in the medium term. How do we introduce universal healthcare coverage to South Africa, how do we do away with the fragmented provision of health services and access based on income?

So the implementation of a formula which at the present moment is that of the National Health Insurance. We have started with the legislative framework being in Parliament. NHI is really the implementation tool for universal coverage.

So those are the three legs — pandemic, strengthening the overall health platform, and then in the medium to long term — universal health coverage.

That’s really where I see myself the next 30 to 32 months.

MH: I would like you to go to your second pillar, which is the strengthening of the health services platform. Do you think we are facing an emergency in relation to other causes of disease and should we be calling it that? 

I interviewed several of the senior doctors at Chris Hani Baragwanath a few weeks ago. The head of acute surgery was telling me how the pattern and burden of disease presentation have changed. Because of lockdown, people are coming in much later with presentations of diabetic foot, late-stage cancers etc. We know we’ve been set back around HIV and TB. My question is, how are we going to catch up again?

JP: Firstly, I’m hoping that as much as we have fluctuations, vaccines do work in terms of reducing the morbidity and mortality, hospital admissions and so on… while they may not reduce infections of individuals.

At the current moment, I’m giving ourselves about three or four months to basically get things stabilised in terms of getting more people to take the vaccines. That will stabilise the pressure on acute demand for beds in terms of the Covid.

But in parallel with vaccinations, and as we stabilise our ability to handle the Covid crisis, we should look at how we should stabilise the other health services and what you have alluded to as non-communicable diseases — diabetes, heart diseases, cancers and so on.

It must not be either/or. As long as we have these waves there will be an acute demand for services. But as we try to stabilise that, let’s try and see how at the same time the diabetic clinic, your hypertension work, screening etc can be implemented.

I accept screening might be a difficulty for the teams out there who are vaccinating. But we should at least record the people who are known, who must get treatment, and we need to track those people so they don’t have to struggle to get treatment.

The vaccines are here. You have got a particular time frame [to implement the vaccine programme], they must be used and you want to prevent Covid disease. But wherever possible we encourage that, as our teams go out, they check the blood pressure of the recipients etc, for example, the questionnaires as you come into vaccination, it’s some sort of a screening because there are questions about your co-morbidities.

It mustn’t be just about routine… if there is some suggestion that someone is hypertensive, are they maintaining their treatment? If there is some indication that they are not, you encourage them to go to their nearest health facility.

On the one hand we are saying as we go out in the mobiles, set up vaccination sites… we don’t have the time because we are also trying to ramp up on a daily basis the number of vaccinations and registrations. But with that little time we have, we should take a few seconds to check on these things and pick up on whether people are actually getting other health services.

Our target is that in the middle of December we should have reached a minimum of 60%, possibly 70% of our adult population vaccinated. We’re hoping if we achieve that, then come the beginning of 2022 the equilibrium will be much better, so that whatever ground we might have lost in terms of our non-communicable diseases, our infectious diseases like TB, HIV/Aids, hepatitis, sexually transmitted illnesses, all those including cancers and so on, we could then start to recover.

We accept the fact that even before this we were not necessarily in a good situation and we have lost even more ground. One is hoping that if we achieve this by the beginning of 2022, we could even try to ramp up most of what we’ve lost.

MH: Various surveys and so on have shown us that the one thing Covid-19 has made much worse is mental health, all the way through from young people to older people. Mental health, as we know from tragedies like Life Esidimeni, has been terribly, terribly neglected. Do you have any special plans on mental health?

JP: Before Covid-19 we had already agreed that we need to make more resources available for mental health at all levels.

Part of the challenge is that we haven’t invested much in the human capital of the professionals in that area. As a result, you have a situation where only 25% of the psychiatrists in the country are in the public service and 75% are in the private sector.

For that to improve, we definitely need to revisit the resource allocation in terms of especially making sure that we can attract more mental health professionals back into the public service; we need to make sure that right at the bottom, from your basic primary healthcare level, there is deployment of sufficient cadreship of trained primary healthcare nurses.

If you look at inpatient facilities, there was a study that was done which basically shows you that if you take your 52 districts, very few of them have inpatient facilities.

So there are all those deficiencies which do need to be addressed. So it can’t just be business as usual.

We are also aware of the additional pressure among health professionals. Talking to colleagues who are in practice, many of them will tell you that ever since the Aids denialism era where they witnessed many deaths in health facilities almost 10 years ago, Covid-19 has brought back those memories and those kind of traumas where you see many lives being lost as a medical and health practitioner.

So this is quite a key area — mental health is a key area which we definitely need to allocate better resources, including human resources.

MH: Do you know how many healthcare workers we have lost due to Covid-19? Are there any figures?

JP: Since the Sisonke vaccination, the numbers have been lower so we haven’t been reporting weekly in our group for Covid-19. We used to report weekly but for the last six to eight weeks we haven’t reported weekly in our Covid-19 council.

MH: My next question is on the human resource strategy for health 2019-2024, which was approved almost 12 months ago. The last one was hugely ignored and not budgeted for. What is your plan here?

JP: We would want to make sure that it is implemented, but at the same time we want to be realistic about the variety of challenges around health human resources. I will draw from my own experience having been in the field and having an understanding of some of the challenges.

Let me start with medical practitioners of various sorts. I’ve already spoken about psychiatrists. You know that it’s not a question of how many psychiatrists we have in the country, but it’s a question of who has access. If 75% of them are available to people who have medical aids, then already you have a problem. And that’s not unique to that category of specialists. Now, the major difficulty in the country is this division between the public and private sector.

Across all the health workforce, almost 99% of all healthcare workforce, except those who are trained outside of the country, are trained in public institutions. But the irony is that… especially the more specialised you go, up to 80%, are now servicing a smaller percentage.

That is just a reflection of how the health resources of the country are divided.

So the question then becomes your resources in public health which cater for 75% of the population, where you have very limited resources. That in itself puts you off in terms of what is ideal, in terms of what you may have on paper as the ideal staffing of a Steve Biko or a Chris Hani Baragwanath — high level academic tertiary services, but the very same people it trains, once they are super specialists you can’t afford them. That is part of the difficulty.

The question then becomes, how do you as the custodian of 75% of the population with 50% of the total resources for health ensure that you have fairly reasonable capacity to meet the demand for health services.

Around 10 years ago, after a strike in the public service, there was then a concerted effort to close the gap, especially within the health sector. The Occupation Specific Dispensation (OSD) came in. But the consequence of that is that the revenue of the state has been shrinking.

Over time and with various wage agreements in the public sector, your top echelon in that OSD has grown so high that you try to limit the gap between the public and private sector and retain them in the public sector. It has become so difficult.

At the current moment, while I don’t know the exact figure, your head of department, let’s say head of surgery at Chris Hani, Charlotte Maxeke or Steve Biko with various allowances, you know OSD, committed over time, earns more than the director-general of the department.

Now, those were the attempts which were made for retaining.

I look at the current take-home [pay] of the interns. I’m not saying they should earn what I earned when I was doing my internship — I couldn’t even afford a second-hand car as an intern. But (their payment) has improved because of all those improvements.

But with the shrinking revenues of the state, what that has done is that it has really compressed the budget of the provinces.

When you look at the various agreements on salaries that have been reached, it has compressed the budget such that the bigger proportion is now going to the compensation of employees.

I get your criticism in terms of approving a human resources strategy and have it gathering dust. In large proportion I must say to you, it’s not out of lack of willingness.

One of the areas that we are looking at is how do we reconfigure staffing ratios. Just look at your staffing of the nurses. At private hospitals you’ll find that in a ward you probably have two out of three professional nurses. If there were 20 nurses in that ward, a maximum of three would be professional nurses. The rest of the 17 out of the 20 would be assistant nurses, enrolled nurses and so on.

But in the public sector, where we have tried to get more professional nurses, the ratio will be completely opposite. That in itself is good because you have got your frontline of better-trained people. But in terms of the cost per unit of treatment, it becomes more expensive.

So those are the kinds of complications that we face as we try to improve our human resources capacity in the absence of an equitable distribution of financial resources. We are going to have to work around those kinds of challenges.

MH: Another important policy that is gathering dust is the recommendations of the Health Market Inquiry into the private healthcare sector made in 2019. Is there any will or any plan to implement some of those recommendations?

JP: We’d like to. It was just after the elections of 2019 when the former chief justice [Sandile Ngcobo] handed us the report. Then seven months or so after that, Covid-19 came in and most of our focus went to that.

In my very first meeting with senior management, I raised the matter that there is no way that we are going to prepare the country towards universal health coverage if we can’t even intervene in terms of the weaknesses which were identified by the health market inquiry.
It’s very clear where we have been found wanting. We have regulatory powers which the judge criticised, that we had not used any of those.

So, I have raised it with our team, we need to just reorganise our management so that we can identify dedicated capacity to look at it, even while the NHI is being debated… look at reforms that can be undertaken which actually speak to that health market inquiry — which in a way would prepare us better in terms of a more integrated approach.

I must say also that there have been some good experiences in this period of Covid-19 between the public and private sectors. For example, when you find a situation where we have to share information about the bed capacity, supplies of commodities such as oxygen… Even now in the roll-out of the vaccination, quite a lot of collaboration between public and private.

There are some examples that we would like to utilise. One of our managers, Nicholas Crisp, last year did a lot of work, working with the private sector, to try and arrive at some common agreement on what the cost for a bed a day for an ordinary hospital bed, ICU and so on would be. So there was some work which was done that we would like to capitalise on. So, definitely not, I wouldn’t want it to gather dust.

MH: If I’m understanding you rightly then, working better with the private sector is something you would attach priority to? 

JP: Without pre-empting things, one accepts that whatever is the final policy in terms of the National Health Insurance, its implementation is going to have to take in the practicality of what we have to pay. If we can start now, without even an act of Parliament, to identify areas where we can find common ground, we can lay a foundation for a transition into a fully fledged universal coverage.

That is why I’m looking at these green shoots as something that we must explore and build on.

MH: My last set of questions are about operational issues and about your attitude to management as the minister. Would you agree that your national department seems very thin or overstretched on skills? Will you also talk about your attitude towards corruption both at the national level and also in the provinces. Is there anything that you can do to sort out the provincial health departments which in most instances are riddled with corruption and mismanagement?

JP: Look, you’re not really exaggerating. We are definitely thin for obvious reasons. There are a lot of vacant positions at a very senior level in the department. A lot of the people are acting… A number of areas where people left and the positions were not filled.

Even if we didn’t have the number of vacancies — the question would be, would we be having the right skills mix? I would admit that even in that situation we would still have a skills deficit.

I have no doubt that in terms of work that needs to be done, in terms of improving the quality of service, in terms of transitioning from the current organisation of our health system into a future one, we would need extra capacity.

One problem is that the whole constitutional architecture creates serious difficulties.

We are a mini federal kind of state. Some people still argue that we are not using the full arsenal of constitutional and legal capacity in terms of what the national government can actually do. But the reality is that because of the nature of our constitutional architecture — in terms of quality improvement, in terms of transforming — you would want as much as possible to see whether you would be able to do it without lengthy litigation.

South Africa is also a litigious society. You would want to limit the situation where, especially within your government, there is going to be litigation either from a different political party with a different political philosophy, such as in the Western Cape. So whatever you do, you’ve got to take the multiparty in terms… which is part of our constitutional architecture.

On the question of how we impact on provinces and the challenges. I must say that this matter of an official from Gauteng who got gunned down is shocking. All indications are the assassins are people who benefited from the matter, which is under investigation. So this is really appalling. The worst you could ever expect. It’s worse. We are not talking about some business where people are selling stuff somewhere and competing for terrain like in the taxi business. We have almost gotten used to this in the taxi industry. But you don’t expect that in health… that people start dying because of issues relating to corruption.

I don’t think this is something that just ourselves as the national health department can be able to solve. One is going to rely on the entire government machinery, including the cooperation of our heads of provinces, the premiers and their teams and their commitment. As a health minister, there is a certain limit — for instance, a health minister doesn’t determine who is appointed as the MEC of health. A health minister doesn’t even determine who becomes a head of department. It all basically depends on the MEC and the premier, even in terms of whether people can be disciplined.

So there are a number of limitations, but I can assure you and the public that in terms of whatever legal powers we have, working in collaboration with our MECs and premiers, we will do our best in terms of guiding our colleagues in the province and nudging them to stay within the straight line, because we don’t want things like this to happen.

MH: Do you have any skeletons, minister? 

JP: No, I can assure you. I don’t have.

MH: But then why did you reappoint David Motau, the person who was appointed as head of the Health Professions Council of SA (HPCSA), who has corruption allegations against him arising from his tenure as head of health in the Free State? 

JP: Just watch this space. It is not public yet, but I did issue a new suspension yesterday. I’m sure he has received it by now. It was all procedural. We were advised that the procedure followed had some flaws. So we had to restart the procedure.

So, after following what the lawyers advised us needed to be done, I signed the letter yesterday. So the process is going to unfold: between my office and HPCSA we’ll start an inquiry into the issues which we have raised in the suspension letter. We just had to follow the process.

MH: Do you expect to lose any more senior staff in relation to the SIU investigation into Digital Vibes?

JP: I’m still waiting for further guidance from the SIU, but preliminarily from what I know, there are going to be difficulties.

I do have some indications… they have already sent some letters which we need to act upon. So in the next few days and weeks there will unfortunately be some action, and that will have some impact also on our capacity as a department. It’s regrettable.

When wrong things have happened and the investigations have led to findings, then people have to be held answerable. It will have an impact on our capacity because, from what I have seen, a number of people will have to be on suspension pending charges, unless it can be speeded up.

The implementers had better make sure it’s speeded up because if you are already working with a skeleton staff and four or five people have to go away for a month or so, it just means your management is thin. But it’s a consequence which must follow.

MH: Is there anything you would like to add in closing? 

JP: I would close by saying that indeed we are in uncharted waters when it comes to the challenges facing the country. We’re not unique in terms of the pandemic situation. I’m very optimistic that we will get out of it working together.

I’ve always been a believer throughout my activist life. I’ve not relied on my own strength alone and knowledge and wisdom. I’ve always relied on people I work with. I will do my best. Whatever task I’m given, I try to do my best. I do understand that that best will not always be enough but I’m going to rely on the support of people — firstly the team within government, within the department, and the support of the president, who I have no doubt in.

All that I can say is that I’m open to views and suggestions from colleagues within the health sector etc.

Health is about life and death — and not like going to home affairs and not getting your passport. We’ll do our best going forward to ensure that we incrementally improve health provision. DM/MC