New CEO of the South African Medical Association, Mzulungile Nodikida, tells Bhekisisa what he learnt about primary healthcare during his studies in Cuba – and why it can work for South Africa.
SAMA’s vociferous and sustained opposition to NHI has been hard to miss. In place of a central funding system for health services, SAMA, Nodikida explained, has been advocating for “a system based on primary healthcare (PHC) principles, focusing on what the WHO calls the health system building blocks, which include leadership and governance, service delivery, health system financing, health workforce and several other components”.
SAMA has strongly advocated against the underpayment of public sector clinicians, too, and consistently chafes the government about the concerningly high number of unemployed doctors in the country.
“We have made representations to the Health Minister, arguing that the employment of these doctors is not only a matter of their own livelihoods but is vital for the health of our country.
“Work rosters in our public hospitals, especially the rural hospitals, have gaps all over, with no second doctor on call to help in case of emergencies,” says Nodikida, whose involvement in professional associations goes back many years.
In 2013, he became the first international liaison officer of the Junior Doctors Association of South Africa (under the SAMA umbrella), a role for which he was well suited, having studied in Cuba.
“We mingled with students from every corner of the globe, swopping notes on our respective health systems and issues,” he added.
He went on to chair SAMA’s Eastern Cape branch for a few years, and in 2018 joined the SAMA board as head of the finance and risk committee.
“You could say that I understand the association very well,” he said, in his distinctively hoarse voice.
An inspiration for life
“It’s a weird voice,” he mused. “I inherited it from my grandmother. I actually wanted to be in the choir at school but – surprise – they didn’t want me.”
Nodikida played soccer and cricket instead, at Ayliff Primary School in Peddie in the Eastern Cape. “It’s one of the best primary schools in the province; I was fortunate,” he said. His parents, two brothers and sister lived in Bell, 30km away, but Nodikida spent much of his early childhood in the home o f his grandfather’s brother.
“I was taken in, with my cousin, to be closer to the school. You know how in every family there is one person with whom you just click? For me, that was my cousin Sinethemba, aka Mtepile. We were very alike and would compete over almost everything. He was a Pirates fan; I was a Chiefs fan. You know how it goes,” he winked.
Sinethemba died in 2000.
“He was brilliant, and I have used his memory as a kind of inspiration in my life,” said Nodikida, who matriculated from Nathaniel Palma High School in 1999, the year in which then President Thabo Mbeki infamously declared that certain antiretrovirals have toxic effects and are dangerous to health, inciting national and global outcry.
“I was aware of that fight but dimly, as I was only starting to become politically conscious,” says Nodikida, who was interested in a career in medicine, but who had first applied to study a bachelor of science information systems at Rhodes University.
“I saw relatives getting old and sick, and my cousin had just died of what I know now was probably renal failure – these things got me thinking about healing.”
Worlds apart
In 2000, he came across an advertisement for a bursary to study medicine in Cuba, but when he looked into it he found that the cohort for that year had already flown out.
“I reapplied in 2002, and was one of 11 applicants chosen,” Nodikida said. The chosen students first flew to Madrid, and then on to Havana. Nodikida was allocated to the Universidad de Ciencias Medicas de Villa Clara in Santa Clara, where he spent six months learning to speak and understand Spanish.
He studied medicine for five years in Cuba, in Spanish, and returned to South Africa to complete his final year at the University of Pretoria, in English. He described the switch as “a nightmare”.
“We had to spend a vast amount of time in our English books, working out, for example, which Spanish abbreviations correlate with which English ones. I remember a day when I was rotating through internal medicine at Steve Biko (Academic) Hospital, and we had a patient with congestive cardiac failure, which South Africa-trained clinicians refer to as CCF. Our prof asked me: ‘What is wrong with the patient?’ I wanted to say ‘Insuficiencia cardíaca global’, but instead I sort of looked at him blankly and said: ‘I know his heart is failing.’”
‘We were trained well’
The widespread dismay on South African medical campuses at the arrival of final-year Cuba-trained students has been widely reported, and Nodikida confirmed he and two fellow Cuba-trained doctors “caught attitude from some professors, who just hated the Cuban programme”.
“We felt that we needed to set an example, show we were trained – and well. At the University of Pretoria, if you do well in your end-of-block exam, you don’t have to write the final exam. I think I wrote only one exam, and in general our group finished in record time, not repeating any blocks,” said Nodikida, who feels that his time in Cuba shaped his approach to medicine more than any other experience.
“We were trained in a communist country that is doing far better than many of the developed countries in terms of health outcomes. If there’s magic in the Cuban system, it’s the focus on primary healthcare and community diagnosis, done mainly by medical students going into the community and categorising each individual within a household according to whether they are well, or well with risk factors, or sick on medication and controlled or not controlled, or sick with complications, and so on.
“You base your interventions on that knowledge,” said Nodikida. He added that he was not alone among his peers in believing, upon his return, that South Africa would benefit from a similar approach.
He returned to Peddie for his community service years, and helped to establish the Eastern Cape Cuban-trained Doctors Forum, which attempted to roll out community diagnosis, and aimed to advocate for a primary healthcare focus in the area.
“We visited people in their homes, believing that if you know what’s wrong with the community, then you’re able to plan accordingly and manage some of these diseases before they become expensive, and need to be cured at a tertiary healthcare centre.”
In his discussions with leaders in healthcare, he said he would often give the example of the country’s approach to tackling HIV.
“South Africa’s Department of Health acts to prevent HIV – in giving people medication to prevent transmission – yet when it comes to other diseases, especially non-communicable diseases, this lesson goes out of the bathtub and we prefer an expensive curative approach.”
He lauds Discovery for rewarding its members for having a healthy lifestyle.
“My grandmother’s favourite food was sweet potatoes, and those green leafy vegetables called isigwamba. They grow everywhere and are actually very healthy, so we could educate people to make healthier choices within the limited resources they have, to prevent non-communicable diseases like diabetes and hypertension. That’s what we learnt from Cuba,” added Nodikida, whose involvement in outreach programmes dwindled as his career path veered from patient-facing clinical practice towards public health and administration.
Keep on learning
Between 2013 and 2016, Nodikida did a diploma in obstetrics and gynaecology. His mentor in the training centre in Gqeberha was Mfundo Mabenge, head of O&G at Dora Nginza Provincial Hospital, who encouraged him to specialise.
“I very nearly did the fellowship in O&G, but by then, I had started to take an interest in the financing, policy and administrative side, and so I decided to enrol for an MBA with Rhodes University Business School. My research subject was the transformation of Nelson Mandela Academic Hospital in Mthatha from a tertiary to a central hospital.”
When a vacancy for a clinical manager position at the hospital was advertised in 2016, Nodikida applied successfully and moved to Mthatha.
In 2018 he became acting director of clinical services for the hospital, a position he held until his appointment as SAMA CEO this year.
“I would like to think that I’ve never lost the desire to learn and improve,” said Nodikida, who did a master’s degree in public health through Peking University between 2020 and 2023, and recently completed training in medical legal mediation.
“The other thing I feel I’ve remained alive to is opportunity. And come to think of it, the two things – ongoing education and seizing opportunity – tend to go together.”
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SAMA’s warnings on NHI Bill met with hostility
SA doctors earn 40 times more than African counterparts
‘Outraged’ SAMA threatens court action over placement of almost 5,000 junior doctors