However, Motsoaledi is proving to be a survivor and a tactician who is determined to turn the health sector around, one health worker at a time, one patient at a time, one clinic at a time, one hospital at a time. Motsoaledi was handed a state health system in April last year which had been neglected for years on the watch of Dr Manto Tshabalala-Msimang and her Director General Thami Mseleku.
For years the pair failed to acknowledge the urgency of tackling a raging AIDS epidemic which is now paying dividends in the form of rising maternal and infant mortality rates, a failing TB control programme and high rates of HIV infection. This is against the background of lifestyle diseases such as cancer and cardiovascular disease waiting for their turn.
Conducting the interview in his spacious Parliamentary office, Motsoaledi leaps from his chair and furiously pages through a file with a PowerPoint presentation.
He points to a graph: ‘Look where South Africa is in terms of cost in relation to performance. In terms of performance we are very low. In terms of cost we are very high, higher than countries like Turkey, Mexico, Chile, China, Algeria, Russia, Philippines, Brazil, and Uruguay. But look at their performance, look where they are. So this will tell you there is something wrong with our healthcare system. What it says is we are spending more per capita. In South Africa we are already spending 8.5% of GDP, so there are countries that are performing better relative to cost.
‘This means we are not managing the health system very well. It says it is not necessarily only funding, but there is also an issue of management. The Integrated Support Team report makes it very clear. At the time when HIV was devastating the country we never increased funding accordingly. I don’t want to get into the politics, but if you didn’t believe something is a problem, you will not go on to prepare for it. So the country was ravaged and devastated by HIV, but there was no increased funding and you saw it weighed heavily on the health care system,’ said an animated Motsoaledi.
Motsoaledi’s graphs show that actual healthcare expenditure decreased at a time when the burden of disease was increasing.
‘At the time we needed to come to grips with what HIV/AIDS was doing to the population. We can now see that at the time there was a quadruple burden the country was supposed to deal with, but the budgeting was still in a straight line as if nothing was happening,’ said Motsoaledi.
Motsoaledi is clear that there are no quick fixes, but he is determined to urgently overhaul the country’s primary healthcare system. Motsoaledi and his provincial counterparts visited Brazil earlier this year and returned impressed with what the Latin American country has achieved by focusing on the delivery of healthcare at community level.
‘We were very impressed and we agreed that this is the best method to deliver primary healthcare.
‘This curative health system the country is engaged with is very destructive, is unsustainable and is extremely expensive. It also explains why we are spending so much and getting very little. Because we are running an expensive system which says everybody must get sick first and rush to the nearest hospital,’ says Motsoaledi.
‘With a disease you start by preventing it. If you only treat it I call it ‘Zama Zama’ because you are not guaranteed of results, you can only hope that you will win.’
Brazil’s primary healthcare system is built around 30 000 healthcare teams who are headed by among others a doctor, a nurse, a social worker and a mental health nurse. Each team includes a community health agent, similar to the community health workers in South Africa.
The community agent takes responsibility for a number of families and visits them, auditing the needs and health status of each person, reporting back to the team where they respond pro-actively to treat or prevent any health issues. The intervention has seen massive decreases in mortality in Brazil.
Motsoaledi is quick to point out that this approach does not mean tertiary services will be shortchanged. ‘Primary healthcare and tertiary services are the pillars of our healthcare system. One is at the beginning and the other at the end. These pillars both need to be strengthened as they have both been weakened,’ said the Minister.
Motsoaledi praised the Western Cape’s vision to roll out a Prevention of Mother to Child Transmission programme ‘when others thought it was not an issue’.
‘And now the results are devastating,’ he said with a quiver in his voice. ‘At that time it shouldn’t have been allowed that only one province went that way and the results are showing. If we believe in PMTCT it must happen in the whole country,’ he said.
Motsoaledi was firm that there would not be a repeat of the situation where the Free State ran out of money and decided to place a moratorium on any new HIV patients accessing antiretrovirals. ‘It is something we cannot allow to happen again, it is just devastating.’
The minister identified tuberculosis as one of the biggest challenges facing the country adding that it was a prime example of how even the curative system was failing.
‘People must know that diseases such as TB used to be treatable. Do you know how big a problem it is for South Africa? It is huge, it is one of the biggest problems ‘ out of every 100 South Africans one now has TB. Of the 22 high burden countries South Africa is number one. A disease which could be treated,’ he exclaimed.
‘So a healthcare system only survives if it is based on prevention of disease and promotion of health, not treatment.’
Motsoaledi grins when asked if he enjoyed being hands on during the recent public sector strike, doing sessions as hospitals.
He sinks back in his chair and relays a story from his days as a Limpopo doctor in the 80s. ‘There was a student uprising at a nearby hospital. The doctors were from Britain and they got so scared they took government cars, went straight to OR Tambo Airport, it was still Jan Smuts, and waited there for a seat to Britain.
‘The hospital was empty and there was a very serious crisis. I was alerted to it after five days and I went there. The staff took me to the gynae ward. I nearly cried. I found women sitting there, who had suffered miscarriages and were bleeding. The nurses just wrote bleeding on their files and moved on. They went septic because nurses couldn’t do anything other than record the bleeding. I had to examine all of them and I finished at two o’clock in the morning. I was alone.
‘At four o’clock I took them all to theatre, alone ‘ put them under anaesthesia and cleaned them up. I did that up to seven in the morning, alone. I then went home to wash and went back to the practice. Then I went to the hospital I did sessions at.
‘I did not demand any payment for that even though I was not working in that hospital. The doctors are gone, what happens to humanity? Can you imagine your wife being there and your wife having a miscarriage with the baby hanging there and nothing happening. These things can happen in life, but we cannot accept them just because it doesn’t happen to us. But it happens to ordinary South Africans who have no other recourse to go to private hospitals or anywhere.
‘They depend on the public health system and that’s where they must get help. They can’t go anywhere else. So what I did at the strike was a continuation of what I have been doing ever since, ever since.
‘I have never cut ties with the medical profession. I was shocked when people said I was playing to the gallery. They don’t know me, I have always done it. I enjoy being a doctor, I enjoy helping people. It has always been my passion.’