How did Aaron Motsoaledi, rather than Joe Phaahla, land the position of Health Minister in the government of national unity, and why was Phaahla demoted to his deputy, rather than Motsoaledi?
We can throw around lot of arguments about their seniority within the ANC, their levels of support for President Cyril Ramaphosa, and whose health policy advice the ANC’s national executive committee (NEC), of which both Phaahla and Motsoaledi are members, will take more seriously.
But ultimately, there’s probably no mystery reason for Motsoaledi’s appointment; rather just plain, practical reasoning, writes Mia Malan for Bhekisisa.
Motsoaledi, who gave up his Home Affairs Minister post to make way for the Democratic Alliance’s Leon Schreiber, has more experience as a Cabinet Minister than Phaahla (15 vs three years), he received more votes than Phaahla in the NEC (Motsoaledi ranks number 27 vs Phaahla’s number 51) and, together, they will make a formidable team, from an ANC perspective, to push through the NHI scheme.
The ANC has fought tooth and nail, also in the provinces, to keep Health Ministries under their rule; and they’ve succeeded in all provinces but the DA-ruled Western Cape.
Where better to send Motsoaledi, probably the ANC’s strongest NHI supporter, than the national Health Ministry, where he’s previously served, to work with someone with whom he has a four decades-long work history?
And Phaahla and Motsoaledi, both insiders, will work together exceptionally well, as they always have.
Here’s why.
They have much in common, with their personal lives and careers bearing striking resemblances.
They’re both in their late 60s, hail from Limpopo, studied medicine at the University of Natal during the late 70s and early 80s, and, as senior ANC leaders, took an exceptionally strong, public stance against state capture in 2016 and 2017 – while they were, respectively, also health (Motsoaledi) and deputy health minister (Phaahla) – by supporting motions of no confidence against the ANC’s former leader Jacob Zuma.
Neither Motsoaledi nor Phaahla is associated with personal corruption and both are strong allies of Ramaphosa.
But most importantly, they have a 40-year history of working with each other – and, particularly when they were younger, Motsoaledi didn’t invariably lead Phaahla; it was often the opposite way around.
As student leaders, for instance, Motsoaledi, as the national correspondence secretary of the Azanian Students’ Organisation, served under Phaahla, who was president, although they were both founding members.
In 1997, after both had served as MECs for three years in Limpopo’s first democratic government, former Premier Ngoako Ramatlhodi axed Motsoaledi as Education MEC and replaced him with Phaahla (Health & Welfare MEC at the time). The reshuffle resulted in Motsoaledi becoming an ordinary member of the Limpopo legislature.
But when Motsoaledi and Phaahla were both elected as National Assembly members in 2009, their careers started playing out with different levels of seniority.
Motsoaledi became Health Minister straight away, while Phaahla occupied Deputy Minister positions in various departments for 12 years, with only a short, much later stint as Health Minister between 2021 and 2024, when Zweli Mkhize resigned because of corruption allegations and while Motsoaledi was Home Affairs Minister.
For eight of Motsoaledi’s decade as Health Minister between 2009 and 2019, Phaahla served as his deputy, as he is now again.
Will the GNU allow the roll-out of the NHI?
Motsoaledi faces a massive challenge: preparing to roll out a controversial NHI Act, which already faces six separate legal challenges, by a government of which only four out of 11 parties support the legislation.
The DA will be a particular dilemma, as its own health policy is based on expanding access to medical schemes – in stark contrast to the Act.
The Act is in many ways Motsoaledi’s “baby”: as Health Minister between 2009 and 2019, he oversaw the development of the NHI white and green papers as well as the NHI Bill.
And although critics have slammed all three documents for being “irrational and incomprehensive”, not incorporating the views of those who made submissions and being unconstitutional, Motsoaledi has made it clear he believes the NHI is the best solution to South Africa’s health system problems.
Not only would he need to get GNU parties to work with him, he’d also need to ensure the National Department of Health (NDoH) writes timely regulations for different parts of the Act and get the Cabinet to approve them.
Moreover, he’d have to drive the process of amendments to at least 10 other Acts, which are required for the NHI to be rolled out, including changes to the Medical Schemes Act, which the DA and parties like the Freedom Front Plus, are likely to oppose.
But, most importantly, Motsoaledi would need Treasury to allocate him a sufficient budget to cover the cost of rolling out the scheme – or it will never get off the ground. That could be anything between R200m and R500m a year, depending on whose predictive calculations you use.
Essentially, nobody knows the cost, because it’s unclear which services the NHI would provide: both Health Department and other insiders say finding the money could be tricky, as several senior leaders within the Treasury have voiced their direct opposition to the NHI.
How will Motsoaledi shape up?
Motsoaledi is an outspoken politician, and has voiced his distrust of the (unregulated and overpriced) private health sector. During his previous tenure he commissioned a health market inquiry into the sector, on which a final report with far-reaching recommendations was published in 2019 – but he never acted on it.
His xenophobic views (he has blamed undocumented migrants, at least partly, for the overburdened state of the health system and some of his Home Affairs policies were seen as “anti-immigration), are problematic, particularly within the context of the NHI.
But Motsoaledi isn’t all about controversy.
He’s also human, and principled. For one, he had the guts to stand up against the President who appointed him by supporting motions of no confidence against Jacob Zuma. He uses government hospitals and has, in his private capacity, often applied his doctor’s skills to save lives.
Motsoaledi has also shown he knows how to galvanise policymakers with an underfunded disease like TB. In 2018, he played an important part in getting the United Nations to hold its first-ever high-level meeting on TB, which resulted in a “powerful political declaration to accelerate progress towards End TB targets” to which countries are still being held accountable (a stark contrast to Phaahla).
Along with TB, increased access to HIV medication (six-fold during his tenure as health Minister from 2009-2019), and also testing and the HIV prevention pill, are seen as measurable successes of Motsoaledi’s previous tenure.
Unfortunately, things are very different when it comes to the state of health systems, which most experts agree, didn’t improve during his previous decade as Health Minister.
The success of the NHI relies almost entirely on the improvement of systems – like information systems to ensure electronic patient files, hospital billing systems, systems to ensure enough staff are recruited, and systems that will ensure the appointment of more competent hospital CEOs.
Motsoaledi’s performance in this regard will be crucial.
Why long-term solutions will define Motsoaledi’s tenure
To be fair, many of the provincial health crises that happened during his previous tenure played out during state capture. But state capture or not, the devastating consequences of the lack of proper public health systems during Motsoaledi’s previous tenure, as well as those before him, are still being felt.
People like Babita Deokaran paid with their lives when they tried to stop the corrupt behaviour of irregularly appointed hospital CEOs such as Tembisa Hospital’s (late) Ashley Mthunzi, who was contracted in 2021 without background checks.
And although Motsoaledi initiated systems for medical schools to increase the number of doctors they train, many now struggle to find jobs, as the system didn’t also address the accompanying increase in provincial Health Department budgets that would be required to pay their salaries.
Motsoaledi’s current tenure will therefore be defined by his ability to develop long-term solutions for complex problems, and this will be shaped by those he employs – which director general, the CEO and board of the NHI Fund – to help him do so.
Tough love, tough choices
He will have to make tough choices: there are exceptionally competent national and provincial Health Department employees, but the opposite is, unfortunately, also true, and, if the many underperforming staff stay on, Motsoaledi’s own performance will be compromised.
And, ultimately, he will need to make sure he doesn’t only ask for opinions, but actually takes the advice he gets.
Malan is founder and editor-in-chief of Bhekisisa.
Bhekisisa article – Rough road ahead: Can Motsoaledi pull off the NHI? (Creative Commons Licence)
See more from MedicalBrief archives:
Motsoaledi to the rescue in plane medical emergency
Motsoaledi era: HIV/Aids success but public healthcare failures
NHI can now be referred to as ‘Ramaphosa-care’ — Motsoaledi
‘Cost containment’ will add to health woes – Phaahla
Court orders Phaahla to act on fraud report