With a coalition government now one of the options going forward after last week's elections, ministerial posts – including the top health job – are likely to be on the negotiating table, as will key ANC policies like the implementation of the National Health Insurance (NHI) scheme.
Speculating on the likely candidates for the Minister of Health position, Spotlight's Marcus Low notes that for most of the past 30 years, South Africa’s Minister of Health was drawn from the ranks of the ANC. But given the dramatic decline in the party’s electoral fortunes and the consequent pressure to enter into coalitions or other deals, the pool of realistic candidates might now be larger than before.
The President has the prerogative to appoint any members of the National Assembly as Ministers, whether or not they are of the same party, and he can also appoint two Ministers who are not Members of Parliament.
It is also relatively trivial for a party to ask an MP to stand down and to have another sworn in, which means candidates who were not high enough on party lists to get seats in Parliament could still be substituted in.
Although technically the pool of possible health Ministers is thus quite large, political realities narrow the choices down considerably.
Let’s start with ANC candidates, given the odds that our next health Minister will be from the party.
First up is current incumbent Dr Joe Phaahla. Although not on the ANC’s national candidates list, he is high up on the party’s regional list for Limpopo and set to become a member of the National Assembly.
Though some might describe his time as Health Minister over the past three years as uninspiring, he also hasn’t been implicated in any scandals or made any obvious blunders.
President Cyril Ramaphosa, presuming he stays in the job, may see Phaahla as a safe pair of hands and consider him the right person to drive the ANC’s stated goal of preparing for and starting NHI implementation. Phaahla previously served as Deputy Minister of Health.
Second in line is current Deputy Minister of Health Dr Sibongiseni Dhlomo, also not on the ANC’s national list, but high up on the party’s KwaZulu-Natal regional list and thus also due to join the National Assembly.
He is a former MEC of Health for KZN and former chair of Parliament’s Portfolio Committee for Health. If Phaahla does not return, Dhlomo would be an obvious replacement.
After those first two candidates, predictions are harder.
Former Health Ministers Dr Aaron Motsoaledi and Mmamoloko Kubayi are on the ANC’s national list and Dr Zweli Mkhize is on the ANC’s KwaZulu-Natal regional list. Given that Motsoaledi’s time at Home Affairs has been something of a disaster, it is not impossible Ramaphosa might return him to the health portfolio where his record was somewhat better.
A return of Mkhize seems extremely unlikely, given the grubby circumstances under which he left. Kubayi’s role for a few months as acting Health Minister was really just that of a caretaker, and a return is unlikely.
One interesting trend is that the ANC has largely chosen medical doctors as health Ministers and deputy Ministers – Phaahla, Dhlomo, Motsoaledi, and Mkhize are all medical doctors.
Current Eastern Cape MEC for Health Nomakhosazana Meth is high on the ANC’s national list, though the poor performance of the Eastern Cape Department of Health in recent years should mean her chances are slim.
In previous years, current Limpopo MEC for Health Dr Phophi Ramathuba was considered a possibility by some, but her name is only on the ANC’s candidates list for the Limpopo legislature and a few ill-judged incidents would make her a controversial choice.
She’s also often been at loggerheads with unions in Limpopo.
Candidates from other parties
Should the DA become part of a ruling coalition or government of national unity, the current Western Cape MEC for Health would be the party’s most obvious candidate for the health Minister role. Dr Nomafrench Mbombo is, however, only on the DA’s list for the Western Cape legislature and will probably again be the province’s MEC for Health.
Jack Bloom, the party’s leading health MPL in Gauteng for two decades, would be a long shot for the Health Minister post, as would Dr Karl le Roux, an award-winning rural doctor who has joined the party.
Bloom is on the DA’s list for the provincial legislature and not on the lists for the National Assembly, so it is not entirely out of the question that he could become MEC for Health in Gauteng.
The EFF received the fourth most votes nationally, having been third in the previous national elections. In the previous Parliament they were represented on the Portfolio Committee for Health by Sophie Thembekwayo (not a medical doctor) and Naledi Chirwa.
Chirwa is last on the EFF’s national candidates list and is unlikely to return to the National Assembly.
Thembekwayo is 36th on the EFF’s national candidates list.
It is also possible that other parties like the MK or the IFP could end up as part of a governing coalition or government of national unity and that candidates from these parties would be in with a chance for the top health job.
There will be many new, and to us unknown, faces in Parliament – no doubt we’ve missed some people with solid health backgrounds in our analysis.
It is also possible someone with health management expertise could be roped in from outside the usual political circles.
Though very long shots, outsiders like Dr Fareed Abdullah – former CEO of the South African National Aids Council and an important player in the early days of HIV treatment – or Professor Glenda Gray, outgoing President of the South African Medical Research Council, might well, and arguably should, be considered.
We’d be surprised, though, if strong outsider candidates like these two were interested in the job, given how politically fraught the role is likely to be.
That said, we suspect the right outsider candidate would be a hit in healthcare circles.
Despite all of the intriguing possibilities, chances are it will be Phaahla or Dhlomo who gets the nod, and in terms of South Africa’s healthcare trajectory, things will probably remain roughly as they are now.
Coalitions will delay NHI
However, there is no doubt that a coalition government will very likely be another impediment to the roll-out of the NHI.
Health experts in conversation in a Daily Maverick webinar this week said although the NHI principle was noble, the Act itself was unworkable, unconstitutional and unaffordable – and in its current form, would undermine provincial governments’ powers, which by law have a degree of autonomy in rolling out healthcare service delivery initiatives.
Currently, public healthcare service provision is a function of the national government, which raises revenue through taxes. However, provincial government departments are at the coalface of implementing healthcare initiatives as they know the unique health needs of their provinces.
Poverty alleviation
National government allocates the taxpayer funding through a “provincial equitable share allocation” mechanism, ensuring an equitable share of the money given to each province is based on a formula that considers both the need for poverty alleviation and population numbers in provinces.
The taxpayer revenue received by provinces through the mechanism is also supplemented by conditional grants from the national government.
The NHI Act takes away the autonomy of provincial governments to execute service delivery initiatives and shifts it to the national government, said Professor Alex van den Heever, chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand.
Through a government-controlled fund envisaged by the Act, the national government will usurp the powers of provinces to discharge health services and initiatives and “shift the provincial equitable share allocation, academic and regional hospitals, and all conditional grant allocations to the NHI fund”, he said.
“The government wants to change the current system and keep the money at a national government level. This is a whole recalibration of the entire national and provincial financing system.”
The government had not changed the Constitution to accommodate this shift, he added.
The big question is whether provinces under coalition governments will allow the health service delivery function to be transferred to the national government, and Van den Heever does not expect provincial governments to agree to such an arrangement.
“I can’t see it happening. Part of the reason you win a provincial government (through an election) is that you’ve got something to do.
“The idea … is that one of the two big functions that provinces run is healthcare. In particular within that are academic hospital functions, provincial tertiary services and regional hospitals.
“That’s a lot that provincial governments have to show that they are effective and functional and capable of doing things. Now you’re saying ‘I’m going to give all of that to the national government’,” he added.
After their healthcare powers are usurped, provinces will be left to run the basic education function.
Van den Heever does not foresee Gauteng, for example, which has four academic hospitals and a number of tertiary and regional ones, agreeing to relinquish the administration of health services under a coalition government.
Stuck in limbo
He expects the NHI Act to be tied up in court for a lengthy period as its constitutionality and merits will be challenged.
There are already several legal challenges from Solidarity, the DA, the Board of Healthcare Funders, the South African Medical Association, the SA Health Professionals Collaboration, and the Health Funders’ Association.
Craig Comrie, chairperson of the HFA, which represents 73% of open medical schemes, said private medical schemes would still be operational for years to come as he sees a long road ahead in legal challenges to the Act.
Contentious issues include the scant details on what medical procedures would be covered by the state, and what role medical schemes will play other than to “cover anything not covered by NHI”.
“There are no benefits outlined,” said Comrie. “Universal health access is a noble intent, but it is not clear which benefits are to be covered. The regulations (to come) will give us clarity. Freedom of choice will have to be outlined, and the role of private healthcare providers.
“The ability to fund this ambitious project will be dependent on economic growth and the ability to attract additional tax revenue.” Comrie said the HFA’s legal challenge to the NHI goes back to the freedom of choice and the constitutional right to health access.
“After that fact, you should have the right to choose and fund your own access to health,” he said.
See more from MedicalBrief archives:
Medical schemes and union kickstart NHI legal challenges
First NHI legal challenge kicks off today as Ramaphosa prepares to sign Bill
Government open to more talks and 'collaboration' on NH