Universal health coverage is one of the hottest issues parties are using in their election arsenal in the run-up to voting day, but academic, immunologist and former Health Ombudsman Malegapuru Makgoba says politics and science make for a bad mix.
Makgoba said the idea that politics has the power to take over scientific thought – as he’s seen during the Aids denialism era – was “a disaster”.
In the late 1990s and early on in the first decade of the 2000s, when the Mbeki Government denied South Africans free HIV treatment because of ill-advised counsel and political agendas, it is estimated that 330 000 lives could have been saved if reason had prevailed.
Yet, “the dynamics between politics, science and medicine continue,” Makgoba said, reflecting on the Life Esidimeni tragedy, as another example.
His investigation, as Health Ombud, concluded that a “high-level decision” to terminate the Gauteng Health Department’s existing contract with the appointed healthcare provider was taken “precipitously”, with “disastrous” consequences: 144 people died and 1 418 faced torture, trauma and poor care: 44 lives are still unacccounted for.
Despite having seen many things in the country’s health system going wrong, “I don’t feel that I should lose hope,” he says.
In Bhekisisa’s monthly TV programme, Health Beat, Mia Malan asked Makgoba what lessons had been learned over the past 30 years
Mia Malan (Malan): We’ve had six Health Ministers over the past 30 years. How has that affected on health policy?
Malegapuru Makgoba (Makgoba): Each one has left a fingerprint in that portfolio. First, we had Nkosazana (Dlamini)-Zuma, who set the blueprint for the national health system by amalgamating the different systems from the homelands and the various provinces into a single one. She was followed by Manto Tshabalala-Msimang, who was part of the Aids denialism era, and almost set us back in trying to address HIV/Aids by pronouncing odd treatment remedies. Then it was, briefly, Barbara Hogan, who terminated Aids denial. Aaron Motsoaledi followed, who, one can say, is largely responsible for promoting the National Health Insurance (NHI), appointing the national health ombud and promoting the largest antiretroviral programme in the world, improving the lifespan of South Africans with HIV. He was followed by Zweli Mkhize, who was responsible for appointing the ministerial advisory committee that helped our country to deal with the Covid pandemic, and now Joe Phaahla, who has managed to get the NHI Bill approved by Parliament.
Malan: There have been great things in terms of policy during these Ministers’ tenure over the past 30 years, such as tobacco legislation and legalising termination of pregnancy, but there have also been bad things, like the Sarafina scandal and corruption during the pandemic. How does corruption impact our health system?
Makgoba: We put a lot of ideas into how the new health system should be, but it’s in the implementation of those policies that we have failed. Take the NHI as an example. Everybody accepts this is the best policy, a transformative policy for the country. But where it gets bogged down is in the debates and the contestation of governance, of how it would affect taxation, how doctors would emigrate from the country if it’s brought into being.
Malan: Is the answer to our health problems really fixing our two-tier private and government health system? Can it be implemented in a way that we will benefit from it? Because the argument is generally that it’s going to be rolled out within a system that’s not geared to make it play out efficiently.
Makgoba: However you look at healthcare, whether universal or not, it’s expensive, with elements that are often not in harmony. I noticed that the Minister has said it should be implemented in an incremental manner – which is perhaps the best way to do it. Because correcting and transforming a health system that has been entrenched for so long is not like a mathematical formula; you have to do it empirically. You learn as you go. Doing it incrementally and learning from each of the increments would assist us, first, to understand what it takes. We know that our tax base is not that big. Implementing the NHI system will be a costly business; healthcare everywhere in the world is costly. Let’s get a few centres accredited properly. At the moment, the hospitals and the infrastructure are not really up to scratch to implement such a system.
Malan: As the Health Ombud for seven years, until last year, you’ve supervised investigations such as Life Esidimeni and the working conditions at Rahima Moosa Hospital in Johannesburg. What do investigations like this tell us about the state of our health system?
Makgoba: First, there’s a leadership problem – across the provinces and across many hospitals. There’s a problem of governance, a problem of infrastructure, of staffing and of professionals’ attitudes. So we have multiple problems, which all hamper the health system.
Malan: Do you feel sad when you see these things in the health system? That some of your work could have been taken further?
Makgoba: Well, I feel sad. But I don’t feel that I should then lose hope. South Africa is my home. Like every South African, I want to live in a country that is successful, that is flourishing. I’m sad that some of the things that I’ve recommended have not been taken forward. But some have, and that I’m happy about.
Malan: Which things have been taken forward that you’re happy about?
Makgoba: In the Life Esidimeni example, the government (Gauteng Health) admitted it had committed what I call human rights violations. She (Qedani Mahlangu, former Health MEC) lost her job, and so did the senior level of the department: Dr TE (Barney) Selebano, Dr Makgabo Manamela, several of the directors. I’m not saying it’s adequate, but it’s one form of a response to the recommendations. The government admitted it had dropped the ball on the whole system.
Malan: You’ve lived through the controversial and difficult HIV denialist period and you were one of the few prominent figures willing to speak out and take a stand. What are your memories of that era and what lessons have you learned from it?
Makgoba: What was really the most disturbing thing for me was that politicians in our country had the gall to think they could define and determine what medical professions understand as a disease and push through the political power to determine the direction of health. During that period, medical professionals were intimidated – sometimes to not even write the correct diagnosis – because they were afraid of the political consequences. That, to me, was the disaster – that the power of politics was taking over the power of scientific thought.
Malan: Do you think we’ve learned our lesson that politics shouldn’t drive science?
Makgoba: No, it continues. It was the same thing in Life Esidimeni … Politics was trying to drive science. The former MEC had received so much advice, from the relatives of patients, from experts in the field – psychiatrists – all advising against this project. The dynamics between politics, science and medicine continue.
Malan: If you became South Africa’s Health Minister tomorrow, what would you do in your first 100 days to fix some of these things?
Makgoba: First, a disclaimer: I will never be Minister of Health in our country; I’m allergic to politics. But for argument’s sake, the first thing I would do is to have a Codesa on health. I would call all stakeholders relevant to health and say: “We are in a new country, we have a new Constitution, based on human rights. How is that reflected in the way we teach medicine, in the way we practice medicine, in the way we provide service in our country? We are transforming South Africa’s health. It’s difficult to do in a patchwork manner; you can’t do it that way. You’ve got to get everybody together and say: “We’re on a new journey. How do we travel and navigate this together?” I think it can be done.
See more from MedicalBrief archives:
SIU to probe Rahima Moosa after ombud’s report
Callous disregard at ‘dirty’, ‘filthy’, ‘unsafe’ Rahima Moosa – Ombud
Good doctors require empathy – outgoing Health Ombud Makgoba
Call for former Premier and MEC to be held accountable for Esidimeni tragedy
‘Dysfunctional and an embarrassment’ – outgoing Ombudsman on health departments