South Africa’€™s new health minister laughs easily. He exudes warmth, goodwill and enthusiasm. Those who have interacted with him, many former foes of his predecessor Dr Manto Tshabalala-Msimang, describe him in glowing terms: ‘€œHe’€™s a good guy (AIDS activist)’€; ‘€œHis heart is in the right place (State sector doctor)’€; ‘€œHe’€™s the best thing that has happened to healthcare in this country (Democratic Alliance health MEC Theuns Botha).

He bursts out laughing when asked if he ever regretted being handed the job. ‘€œI need to be honest with you. For the first time in my life I had to go for a massage because every neck muscle was tense when I started in the job, I had a headache. My shoulders? Phew, I felt myself carrying a really big weight and sometimes I used to wake up at three o’€™clock and not go back to sleep again. It was very heavy I’€™m not going to lie,’€ he grins.

Almost a year into the job, Motsoaledi is slowly trying to heal a broken health system and he has some very clear ideas on what tonic it needs, but he is also someone who listens and has consulted widely and still does.

Many believe that his biggest challenge may not be trying to find the right remedy for the ailing health system, but the people or capacity to support him in achieving his vision. Under Tshabalala-Msimang and her Director General the national health department hemorrhaged competent staff with only a few left standing. Motsoaledi is now trying to win back the capacity he needs.

How much of an issue if the lack of capacity for him? ‘€œHuge. Huge. Make no mistake about it, huge. But we are trying our best to bring back some of the people who have left,’€ he says, adding that he is still searching for a Director-General after he failed to find one in the first round…

Within a couple of months Motsoaledi has set up a high level committee to advise him on the overhaul of South Africa’€™s health system or National Health Insurance (NHI) system as it has been branded by the ANC health committee. The committee has met twice and is working out the finer detail as well as the costing of such a programme, something Cabinet has requested.

Is he in a position to share with South Africans his vision of the much-debated NHI system?

‘€œAll the countries, whether rich or poor, are actually searching for a best model of health care financing because it is a problem worldwide.   Even one of the most developed countries in the world, the United States, the biggest democracy in the world, they are at war if I may put it that way looking for the best model,’€ says Motsoaledi.

The minister is clear that the Constitution compels him to take action. ‘€œIt clearly states that health is a right and the state must do everything in its power to make sure that this right is exercised in terms of access to health. That’€™s what the NHI is all about. Now there’€™ve been lots of debates because some people are scared of it. Coincidentally we were told by many counties that it happened everywhere. You have a war between the haves and the have-nots. Those who have got money believe that all their money will be gone and those who are poor obviously clamoring for better health care,’€ explains Motsoaledi.

He relays a conversation he recently had with someone advising him on NHI, a professor from the United Kingdom. ‘€œHe said we are a very unequal nation and that we need this more than anybody else because the inequality in our country is the highest in the world and therefore the issue of social solidarity where the rich much pledge solidarity with the poor by subsidising them is important, more than in any other country,’€ says Motsoaledi.

However, Motsoaledi cautions that NHI will not be ‘€œan event’€ where South Africans go to sleep one night and wake up the next morning to find an NHI system. He is clear that is will be implemented as part of his wider 10 point plan for health and that the upliftment of the entire health system will go hand-in-hand with the NHI roll-out which could take many years.

Key to Motsoaledi’€™s success is the co-operation of the provinces. The mess in the Free State in 2008 and 2009, which saw thousands of people denied antiretrovirals and other lifesaving medication when the province ran out of money, exposed the danger of not being able to control the provinces. Most of the provinces are also in the red with overdrafts totaling billions of Rands.

In many areas the national health department gives policy direction, but the provinces have the final say over how and where they direct their resources. This has seen South Africa develop some of the best policies in the world only to reach a dead-end at provincial and municipal level. However, when things collapse, the national health minister is held to account.

‘€œWe give money for ARVs, if they are not there it is me who is questioned. They say ‘€˜Minister what has happened?’€™ Last week, I’€™m not going to name the province yet, we had to renegotiate with the company that supplies ARVs to supply one province because they were not being paid. Do you know why that aggrieves me? Because in October I convinced the cabinet and the minister of finance and they understood very well. Minister Pravin Gordhan gave us R900-million. That money was distributed to provinces. How does it come that we have to go and beg and negotiate with the one of the suppliers? What happens? Some provinces which are on an overdraft ‘€“ whatever amount you give them goes into the overdraft,’€ says Motsoaledi.

Motsoaledi is clear that he will be working closely with Gordhan to ring fence certain budgetary items as ‘€œuntouchables, non-negotiables’€, forcing provinces to invest the money where it is needed.

‘€œ Immunisation of kids and primary health care is one of them. School health is one of them. The issue of maternal and child health is at the centre of those. Nobody must tell me that these things are not. Because these things have far reaching implications and I can’€™t just sit here and fold my arms,’€ says Motsoaledi.

Motsoaledi cautions that he is not at war with the provinces and that he has a good working relationship with the MECs, but also cites the example of another unidentified province which had run out of iron tablets and started prescribing blood transfusions for the patients who were anemic. Motsoaledi’€™s eyes flash behind his rimless spectacles: ‘€œThat’€™s outrageous and I’€™ll tell you why. Iron tablets are one of the cheapest pharmaceutical items, but blood is extremely expensive. Not only in monetary terms, it’€™s a rare commodity.

‘€œWhen I was a medical student, when there were new drugs which came in, you will never prescribe it unless the Professor approves it. It was expensive and we were not allowed to give it just like that.

‘€œYou don’€™t go and take a bazooka to kill a fly on the wall. That is the most expensive way to kill a fly. But I can tell you that type of things seems to be happening in South Africa. Those are some of the things we are going to change. If a province is doing that, I can’€™t fold my arms. We are going to have to make them change so we can save the cost for the country, so we can do more,’€ he says.

Motsoaledi is adamant that South African’€™s current approach which is geared toward the curative is unsustainable and unaffordable and that the focus needs to change to prevention, at all levels.

He uses cholera as an example.

‘€œWe have a sewerage pipe leaking into a river, but nothing is done. Our system is geared towards waiting for 100 people to get cholera and then you rush there, find them, connect drips and put stretchers there and call the WHO. Treasury gives money because it’€™s an emergency. But it could’€™ve been prevented with the healthcare inspectors stopping it immediately the day it happened. All those things must come back into the healthcare system.

‘€œWe need to close the tap. If you keep on mopping, the mops will get finished and you will get 100 mops and keep on mopping. And in HIV/AIDS and other areas we need to close the tap. I’€™m really begging the country, leaders and everybody, we have got to help each other to close this tap, absolutely.’€

Motsoaledi often uses his experiences as a young rural doctor to make sense of current challenges.

‘€œYou never allowed anyone to die in your hands. There is one incident, I cannot forget it. One day I was in theatre alone to do a Caesarean section, no anaethetist. This woman just arrived, she had 10 kids and she was going to deliver the eleventh and her children came to see her that day.

‘€œI saw them when I came to fetch her for theatre. While I was stitching up the mother the sister screamed that the baby was not crying.   I rushed in, resuscitated the baby, did the incubation and gave oxygen. When the baby started crying, the colour came back, because they turn blue when they are not able to breathe.

‘€œI rushed back and left the nurse there she was not aware that the lady was bleeding. When I returned there was no blood pressure and no pulse, you know I looked at the door, I thought about the 10 kids who I saw visiting. I felt like bolting and just disappearing into nowhere. I mean it was one of the biggest crises of my life. But I started by putting up a drip because I found that the one that was there was stuck and the sister didn’€™t detect that. I started putting up an intravenous line. I can tell you when the monitors there started showing a pulse everybody was cheering, they clapped hands and she lived, she lived. I can tell you I was not going to forgive myself if she died.’€

‘€œNow we want to bring some of these values. Why should women die under our care? Why should it be normal and acceptable for somebody to die? It shouldn’€™t, because it was not so then, why should we accept it now.’€

‘€œThe death of a woman in pregnancy is not an ordinary death, it’€™s extraordinary. Do you know how many people are going to suffer there? Kids left behind, a husband left disorganised, maybe starting to drink, losing his job because he’€™s disorientated. It’€™s a very big thing, so it was not allowed to happen. But these days it looks like it’€™s just one of those things and some doctors will tell you, look 46 % of the women are HIV positive, what can we do? But we know for sure that for the remaining 54% there is a lot we can do.’€