KwaZulu-Natal's Yogan Pillay, now with the Bill & Melinda Gates Foundation where he leads HIV and TB delivery, has been an unassuming but key player in the national Health Department, whose work in TB and HIV has gone global. He has the ear of not just Health Minister Aaron Motsoaledi, but of major and leading players in the field, writes Sean Christie for Bhekisisa.
Born on a farm outside Port Shepstone, Pillay wound up at Johns Hopkins University in the US, where he would earn a PhD. He rose through the ranks at the Health Department, becoming known for his insistence that healthcare models be grounded and practical, but his tenure was not without criticism.
An HIV doctor working for an NGO in Eshowe tells a story about a visit from Yogan Pillay in 2019. Their HIV project had managed to achieve the UNAids 90-90-90 targets in a fairly large population, and Pillay, who was responsible for the country’s HIV programme back then, had journeyed to Eshowe to find out how they had done it.
“We heard he doesn’t mince his words, so everyone was standing a little straighter than usual,” the doctor says.
The team had expected a cavalcade of luxury vehicles but Pillay arrived driving an inexpensive hired car. His first order of business was to ask to be introduced to all of the nurses.
“That put everyone at ease. But the moment he was done he said to me, okay, now tell me how you did it, and I’m warning you, if the secret is money, I’m not interested,” the doctor recalled.
I was reminded of this when I visited Pillay at his home in Pretoria East in November. Pretoria is home to many current and former government leaders, most residing in luxury in highly securitised compounds.
The housing estate I arrived at was nondescript, with no guards controlling access — Pillay himself let me in, dressed in a T-shirt and shorts.
He ushered me out to the stoep in hushed tones.
“My son is studying for his (matric) exams, he doesn’t like a lot of noise,” he said, offering food and a hot drink. His son – Vishay – had been provisionally accepted into four medical schools.
“The only things I’m proud of are my son, my publications, and my work in the department,” Pillay said, as an opening statement. Then, he said he felt sorry for me.
“I have no idea what you’re going to write about. My life story isn’t particularly interesting. I mean, very little that has happened in my professional life has been by design. I’ve been fortunate, really.”
Extreme modesty usually signals rich pickings for the writer of personality profiles, but Pillay insisted he was the exception.
But I had already talked to enough people in healthcare circles to know it wouldn’t pan out that way. Pillay, I was told, was hard-working (a workaholic, some said), practical, strategic, communicative. But there were other words, too: acerbic, meticulous and stringent.
I mentioned the Eshowe story as a case in point. He chortled.
“It’s important to engage with frontline staff, and my concern is we don’t engage them enough. I am as much to blame as anyone. When I was sitting in the national department, developing policies, who would we call for input? We would call all the academics … often forgetting about the healthcare professionals who have to implement the policy, and the people who use the services.”
Pillay would become known for his insistence that healthcare models be grounded and practical. Several of the department’s NGO partners recall being chastised by him for coming up with innovations that were impossible to implement at scale, being unaffordable, or otherwise unacceptable.
“I probably get that from my dad… he was a real stickler. His ethos was basically that you’ve got to be able to take things on, apply yourself, and get the work done in the most practical way. Never leave a thing half done,” he said.
Child of the Hibiscus Coast
Born on a farm outside Port Shepstone, Pillay was one of four children. Their parents were “grafters”, who “got it from their parents”, he said. His maternal and paternal grandfathers, respectively from India’s merchant and farming classes, arrived in South Africa with nothing, and became relatively prosperous, buying shops and farms.
“My maternal grandfather was a real entrepreneur. He had the first Buick on the South Coast,” said Pillay, who attended the local farm school before moving to RA Engar School in Marburg – “Port Shepstone’s Indian area” – when his father took a teaching post there.
Pillay continued to the Indian High School in Port Shepstone but moved to Pietermaritzburg when his father was appointed headmaster of a school there.
“I attended Raisethorpe High, where all the teachers were Indian. They were very straight, you couldn’t mess around, and they all knew my dad, so I had to behave,” he said.
After matriculating, Pillay was accepted to study medicine at the University of the Witwatersrand.
“As a non-white I needed ministerial permission, which I duly received, but I couldn’t stay on campus – a problem, because neither I nor my parents had ever been to Johannesburg. My dad got a cousin to drive me up, and we started looking for accommodation.”
Eventually, he located a relative “a couple of bloodlines over”, who allowed him to sleep on the couch in her Lenasia home. He found it deeply uncomfortable.
“Those four-room houses in Lens had a toilet outside but no bathrooms. To shower, you had to go to another house a few streets away. I never understood why the apartheid government would build houses with a toilet, but no bathroom,” he said.
To get to lectures, Pillay would bus into the city early in the morning, and walk through Braamfontein cemetery, repeating the long journey at the end of the day. He was miserable.
He dropped out after a year, enrolling instead for a Bachelor of Science at the University of Durban-Westville, where he “did rather better in psychology than physiology or biochemistry”, leading him to apply for a place in the University of Natal’s clinical psychology programme.
There he completed an honours and masters, and gained both in-patient and out-patient experience on rotation through Fort Napier, Town Hill and Northdale Hospitals. He worked in clinical psychology in Pietermaritzburg for three years and then lectured at his alma mater for three years before deciding to do a doctorate.
Levelling up
A Fulbright scholarship to study community psychology at New York University (NYU) landed Pillay in Washington Square in Manhattan, “with two big bags, very little money and no idea where to find the (NYU) housing department”.
The course wasn’t what he hoped it would be.
“They could only teach me statistical analysis. Thanks to the grounded experience I’d had in South Africa, there was not much left to learn from a community psychology point of view,” added Pillay, who was also struggling to survive in New York, where his rent bill for a shared apartment chewed up three quarters of his stipend.
He won a Kellogg scholarship – “more money” – and moved to Johns Hopkins University in Baltimore, to study under Spanish sociologist and political scientist Vincente Navarro. In 1995, he finished his PhD and decided to return home.
“Quite fortuitously, the national Department of Health had advertised some positions, one being the director for health systems role. I applied, got it, and moved to Pretoria in 1996.”
He found the environment “at least as intimidating as New York”. “It was still very white, everybody … in grey shoes and all that,” he said.
After three years of office-based work, Pillay was feeling removed from healthcare realities.
A United States-based NGO called Management Sciences for Health then offered him the reins of a project to strengthen primary healthcare in the Eastern Cape. Rather than lose Pillay, the department’s then-director general Ayanda Ntsaluba allowed him to keep his office, and split his time 50-50, “with the proviso that they (the American NGO) pay my salary”.
He led that project – the Equity Project – later taking the job of chief director for strategic planning in the National Department and then deputy director for Health Programmes.
In that vast role, which he held from September 2008 to May 2020, he oversaw the HIV & Aids, TB and maternal, child and women’s health programmes.
It would be the making of Pillay.
In his time, mother-to-child transmission of HIV dropped from 6% to under 1%, and the number of people on antiretrovirals rose from around 350 000 to more than 5m. Between 2008 and 2018, life expectancy in South Africa increased by 10 years.
“In 10 years it increased by a decade, a thing for which there was no precedent anywhere in the world. Of course there were other factors in play, like the government pushing forward on education, access to clean water and sanitation and all of that, but by all accounts the major contribution to expanding life expectancy was the significant increase in the number of patients on antiretrovirals.”
An extraordinary thing to be able to claim to have had a hand in, but context is important.
Before 2008, a high number of avoidable deaths – in the hundreds of thousands, at a conservative estimate – had occurred as a direct result of healthcare policies that prevented people with HIV from accessing antiretroviral drugs.
These policies were largely a manifestation of the Aids-denialist views of President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang. While Pillay was not directly responsible for the HIV programme under Mbeki, many in the treatment activism community are yet to forgive his failure to speak out.
One HIV doctor I spoke to bitterly recalled being admonished by Pillay after he allowed members of the Treatment Action Campaign to protest outside a clinic Tshabalala-Msimang was due to visit.
Pillay shrugged when I brought this up.
“Manto insisted that a long list of criteria be met before patients could be initiated on treatment. My colleague Nono Simelela, who was head of the (HIV) programme at the time, found her (Tshabalala-Msimang) to be completely unyielding, and so we took a decision to quietly allow treatment to be provided where possible, under the noses of Manto and Thabo. Western Cape did it, and KwaZulu-Natal did it, but generally speaking, the provincial MECs (for health) were scared,” he said.
Changing of the guard
Within months of Pillay taking on the DDG role, Mbeki was replaced by Jacob Zuma as President, and Aaron Motsoaledi took Tshabalala-Msimang’s place as health Minister.
It is clear Pillay has a lot of time for Motsoaledi.
“He (Motsoaledi) likes big ideas. In fact, he has a tendency to make them even bigger than you envisaged,” he observed.
For starters, Pillay and his team wanted more money for HIV. A lot more.
“We consistently used data to get the Treasury to give us more money for HIV and to show programme progress. We especially focused on incidence and mortality data.
“We said (to Motsoaledi), if you want to decrease incidence (the rate of new infections) and mortality of HIV, the best evidence we have through a model is that you need to test and initiate, on treatment, a certain percentage of people…this is what it will cost us to do that in South Africa.”
Motsoaledi approached the President with this argument, and Zuma took it to Pravin Gordhan – then Minister of Finance – and said, “Go find the money for these guys”.
“So Pravin went and top-sliced from all other departments to give us the conditional grant for HIV,” Pillay said.
On a structural level, the idea was that HIV treatment should become a primary healthcare service rather than a hospital-based service, with nurses, instead of doctors, managing patients.
Motsoaledi hardly needed convincing.
“He approved it, the nursing council approved it, and we moved the entire programme out of hospitals and into clinics. From this new footing we saw large numbers of people being initiated.”
To radically expand HIV testing and counselling, Pillay pitched what many regarded as an impossible idea.
“It became known as 15 in 15 – 15m tests in 15 months. A lot of people said that was mad, but we were able to do that.”
Moving to the outside
When Pillay resigned from the department in 2020, the gossip was that it was in reaction to being passed over for promotion to the director-general position, a theory Pillay rubbishes, insisting he is “a technical person through and through, not a politician”.
“I have a simple recipe I’ve been using for years. Make sure you know your numbers, that’s important. Be sure to have a strategy, and an implementation plan. Then, do your monitoring.”
That year Pillay joined the Clinton Health Access Initiative (Chai) as its country representative and global adviser on universal health coverage. But towards the end of 2022, he received a call from South African expatriate Trevor Mundel, one of the presidents at the Bill & Melinda Gates Foundation.
Mundel said he was looking for somebody with experience in delivering health programmes, specifically TB and HIV programmes.
“I thought he was just asking for my advice, so I told him I thought it was a good idea, because while I was with the department, we were forever criticising the Foundation for developing shiny new things without really bothering to work out how they were going to get them to the patient.”
When he realised he was being offered a job, he hesitated.
“I said, ‘I’m not sure that you guys are serious about delivery, you know?’”
He relented after learning that he would be working with former UNAids executive director Peter Piot, who had been brought into the Foundation as an adviser.
“I knew Peter from my HIV work and said I’d join him on one condition: that I remain working from South Africa, because all of our work is in this part of the world. So here we are,” he said with a relaxed smile.
Pillay is not the first senior Health Department figure to have joined a major international player (former TB director Lerole David Mametja was in a senior role at TB HIV Care from 2019-2023), and he will not be the last, but it is a career move that raises eyebrows.
A senior governmental policymaker told Bhekisisa: “Health planning has never been politically innocent or ideologically naïve. Those organisations that we call development partners are not innocent, and owing to their financial power, are able to impose their own strategic goals, to the extent that if we are not careful, our senior leaders become functionaries of those funders, both when they are in service and out of service.”
Pillay is happy to tackle the insinuation.
“There are pros and cons to philanthropy. It’s good to be sceptical. I think it’s fine if donors fund innovations that governments can take to scale, feasibly, and I think it’s fine if they function as thought leaders, but donors should not be funding routine services. That’s how dependency happens. A country like South Africa should not be dependent on donors.”
Lessons to be learned
South Africa is doing poorly on HIV compared with other countries in the region, and improvement will not happen without strategic partnerships, Pillay pointed out.
“There are various factors. Quite a few experienced people have left the department, and there are a lot of people in acting positions, so then it’s difficult to take decisions.”
Relations between the national and provincial Health Departments also need to be improved.
“The provinces will only take your guidance if they trust you, and if they think what you’re telling them makes sense,” added Pillay, who reached out to Motsoaledi after his re-appointment as health Minister in July 2024, offering his assistance.
Not too long afterwards, Motsoaledi convened, with Foundation funding, a retreat for senior healthcare leaders from the national and provincial governments, at which a plan was devised for, in Pillay’s words, “moving the needle on strengthening management, improving health outcomes, strengthening facility-based service delivery and dealing with human resources issues”.
Pillay has also been working with both the department and PEPFAR on a plan to put an additional 1.1m people on treatment in 2025, to help the country reach the UNAids 95-95-95 targets (the plan was announced by Deputy President Paul Mashatile on World Aids Day last year).
“As we did with the 15 in 15, the plan is to have a high-level team drive this,” he said. My surprise at the extent of his influence must show, because Pillay quickly added, “Look, I’m an insider outsider. I have worked in the department… the Minister knows me.”
With the future of US Government funding to global health in doubt under the Trump administration, and given that South Africa’s HIV programme is heavily dependent on PEPFAR and the Global Fund, having someone with Pillay’s experience and contacts, to both government and donor organisations, is easy to understand.
Bhekisisa article – Yogan Pillay, SA’s healthcare’s insider outsider (Creative Commons Licence)
See more from MedicalBrief archives:
HIV now at two-decade low for pregnant women
The rights and wrongs of the South African health system
World Aids Day: SA to get new state-of-the-art HIV treatment