By month end, South Africa will have a new Minister of Health. Ufrieda Ho asked some academics and activists what qualities that person should have to tackle the key health issues the country faces.
The precise health minister South Africa needs right now may not exist. But the portfolio still demands that the person appointed to this critical position be up to the job.
The appointment, when it happens, will come against a radically shifted political backdrop. Firstly, the elections results of the May 29 point to a coalition government for the first time in 30 years of democracy. The final configurations of a likely government of national unity is still anyone's guess. And secondly, the National Health Insurance (NHI) bill is now an Act. President Cyril Ramaphosa signed off on the bill just a fortnight before the elections. It means by law, the work on the advancement of NHI must begin even as the contentions and contestations remain as thorny as ever.
Another reason why getting the right person matters is the money that comes with the portfolio. Annual government spending on health is in the region of R270 billion. Most of this spend is currently directed via provincial health departments, but flows under NHI will be nationalised and the NHI Act gives the minister extensive powers over NHI, and indirectly, the NHI fund.
At the same time, problems like entrenched health sector corruption and high levels of medico-legal claims against the state remain acute. Health budgets have been shrinking in real terms over the last decade. Financial shortfalls and shortages of healthcare workers in our health facilities are dire, while health needs enlarge.
Bridging ideological divides
Fatima Hassan, a human rights lawyer and founder of the Health Justice Initiative, says: "Policymaking in a coalition government is going to be so difficult - a Herculean task. And the place where you're going to feel it most acutely is in health, because we have a dual health system and because NHI is sitting on the table."
She says the role of minister will call for an astute politician. She says: "It must be someone who can work with different parties as well as constituencies in different sectors to try to bridge a number of these ideological divides.
"Health is a lightning rod for the differences between the different political parties; we saw this in how the parties campaigned for or against NHI," she says.
Hassan says the worst case scenario will be someone in the position who is a "placeholder minister" who stalls on reforms, is a person more concerned with "calming the markets" and someone who will simply play the political long game waiting it out until the next elections.
"It must be someone who is able to work on creating a fairer system for access to proper healthcare services across the country, not just in specific provinces. They must invest in health infrastructure, invest in human resources for health, and invest in some of the more positive aspects of preparing for national health insurance," she says. She adds that the person must prioritise fixing the "glaring issues in the NHI Act" to avert looming law suits.
In addition, Hassan says the minister must be someone who can stand up to the bullying of private sector power, including the likes of big pharma, and must be able to show leadership on domestic health issues while also being a strong Global South voice on international platforms to champion global health equity.
'Health is more than a biomedical response'
Professor Scott Drimie is a researcher at the University of Stellenbosch and director of the Southern African Food Lab. Drimie works on food systems and food security and how these intersect with the social determinants of health.
For Drimie, South Africa's health minister must be a person with an expansive leadership style; a person who is able to work across government departments and also be awake to the grassroots realities people face. Around 85% of people in South Africa rely on public healthcare.
"The minister must be able to grapple with the lived reality of most poor people and put in place a health system that supports the most vulnerable.
At the same time, that person should be someone who understands that health is more than a biomedical response - health is also issues like food security, sanitation, stable livelihoods and safety," he says.
Another quality Drimie highlights is that the minister should be open to collaboration and experimentation. He says there has to be a "whole-of-government" approach and a "whole-of-society" approach. The Department of Health cannot achieve its key performance indicators on its own; it needs to collaborate with departments including social development, education and basic education.
"It must also be able to be bold with programmes and work with communities directly as well as with civil society, health advocates and health activists," he says.
Reform of bureaucracies in the health department must also be something the minister tackles, Drimie says. He says it means appointing effective managers who are not micro-managed or politically influenced. Effective implementers of policies and programme, he says, can be a counterweight to politics.
"Politicians can come with very short-term, very narrow party politics," says Drimie. But, he adds, enduring and relevant health programmes survive beyond political tenure and are more likely to achieve positive health outcomes.
Put people first and 'show humility'
For activist Anele Yawa, who is secretary general of the Treatment Action Campaign, we need someone who puts people first. He says the minister must serve the interests of people and show humility for the office.
"The minister must not be someone who pushes his or her agenda. A minister is appointed; he or she did not submit a CV to us. So a minister must understand that there will be times when we as citizens and civil society will disagree with them. It's because we will continue to speak truth to power, we will continue to hold them accountable; whatever the new coalitions will look like," he says.
"Our ministers must not be arrogant and think it's because we hate them. We will disagree and we will fight because it is an effort to make sure that things are done the right way and we can bring health services to the majority - it's that person who is working class, black and is a woman," says Yawa.
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He says it means a strong minister must be one who maintains an open-door policy; who arrives at community meetings in person; take calls personally and engages.
Yawa says it's also critical that the seventh administration is one that works cohesively. "We voted on the 29 May for a contractual agreement with government; not a fashion show. It means that we don't just need a good health minister, we need a good administration that delivers on water and sanitation, on education and on social development, and so on."
Motivate and inspire
Professor Lucy Gilson is head of health policy and systems division in the School of Public Health at the University of Cape Town. Her top qualities for a good minister also centre on people skills. She says the health minister in South Africa must be an inspiring leader.
"The person must be able to motivate health workers and managers to be the best public servants they can be.
"The person must also inspire the public to trust in the public health sector," Gilson says.
The new health minister must have strategic management skills, she says. These will be necessary to navigate the complexity of power and interests in a coalition government and to figure out how the NHI will take shape.
In the end, she says the person in the post should have patience and persistence. She adds: "Bringing change to the health system is a collective and sustained effort over time. The minister must be able to strengthen capacity, assemble coalitions and networks of learning, experience and mutual accountability."
