On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.10 Cape Town Oct. 2009
Experts review motsoaledi's first 3 months
He's riding a wave of professional goodwill, positive feedback and public desire to see him tame the monster of a public health system he's inherited, but have Dr Aaron Motsoaledi's first 120 days as Health Minister justified the hope he's carrying?
The answer, with some strong caveats around the incoming National Health Insurance (NHI) system, from health care experts in fields as diverse as HIV/AIDS, academia, professional boards and the private sector, is a qualified yes.
Izindaba interviewed five key leaders in these fields on how the former GP and ex-Limpopo education minister has been performing since he's been in office.
It's been a period marked by NHI vitriol, wildcat doctor strikes, massively expensive provincial budget mismanagement, swine flu hysteria and ARV rollout tragedy.
His two predecessors, Dr Manto Tshabalala-Msimang and Barbara Hogan, excited contrasting opinions, the former for helping shape the demon Motsoaledi now has to slay and the second for outspokenly sacrificing herself to help prepare him for battle.
President of the HIV Clinicians Society, Dr Francois Venter, has reduced his own expectations, saying Motsoaledi had been 'dealt an almost unplayable hand'. 'Hogan uncovered a lot of problems in her short tenure and allowed him at least a fighting chance, but Manto's era will be felt for decades to come - it was not just HIV that was a victim of her maladministration, but the entire system,' he said.
The energetic and 'accessible' Motsoaledi had so far 'not put a foot wrong', admitting public hospitals needed overhauling, empathising with striking doctors, allaying swine flu fears and promising financial support to a stuttering Free State ARV rollout.
'The entire system needs re-tooling but he seems to be the right man for the job. I feel very sorry for him, he's inherited hell. The proof will be in the next three years, when tough choices and action will be required for the desired outcomes,' Venter said.
He cited 'underperforming' provinces like KwaZulu-Natal, which needed immediate and tough fiscal discipline to burrow its way out from under a R2 billion deficit, ongoing incompetence, fraud and 'appalling' human resource management.
Federal system mitigated Manto's influence
'With Manto this provincial (health) autonomy was a blessing but for Hogan it was the biggest headache as she battled to enforce some authority, insisting money be spent as intended instead of how each MEC thinks it should be.'
He's 'heartened' by Motsoaledi's insistence on fixing public health care management systems and improving delivery capacity instead of 'trying to spend his way out of trouble' ahead of the NHI.
On the Occupation Specific Dispensation (OSD) increases for nurses, Venter's biggest criticism was that there was 'no link whatsoever' to performance (now an annual requirement for doctors in terms of their OSD settlement, thanks to Hogan).
'Motsoaledi's inherited this monster so we must give him some time to see what he can do. He seems to have assembled a decent team around him. We're depending on him to turn the Titanic around.' Venter said: 'Everybody desperately wants him to succeed and they're willing to let him make some mistakes - there's a great deal of goodwill towards him.'
'At least he listens' - Mariba
Professor Thanyani Mariba, Chairperson of the South African Medical and Dental Professions Board (SAMDPB) and Dean of the Faculty of Health Sciences at the University of Pretoria, was pleased that 'at least he (Motsoaledi) listens'.
Mariba said Hogan's caretaker tenure was too short for any decent comparison. He'd been impressed by a report from his deputy dean, Professor James Ker, after a recent meeting between Motsoaledi and the national committee of medical deans. 'James was able to call him aside and express his individual concerns and he listened intently - that's what people are saying: he listens before making up his mind.'
Mariba fought tooth and nail during the Tshabalala-Msimang era against draft legislation enabling the health minister to appoint the majority of people to the Health Professions Council (HPCSA) board, coming up against its Registrar, Advocate Boyce Mkhize.
Motsoaledi has so far held off signing into law the final HPCSA board shortlist, implying that he's heard the professionals' opinion that it emasculates their power to nominate and elect their own people. 'Obviously he's got a grasp of things and we hope they'll move along now,' Mariba said.
Dr Chris Archer, CEO of the Private Practitioners Forum of South Africa (PPFSA), had some very specific concerns, while his overall response was 'guardedly optimistic, though I'm not terribly confident'. His central worry was the government's 'turnaround' on 12 August via a State attorney's fax to the PPFSA signalling an intent to contest the PPFSA's court application to secure a properly cost-based Reference Price List (RPL) process.
With the NHI looming, the RPL will play a salutary role in determining the contract prices for private services which most observers believe will be at fixed prices. Current government regulations say the RPL must be cost based but the PPFSA and 22 other private stakeholders want this principle made sacrosanct. The health department was happy to leave the court application unopposed - until 12 August.
Motsoaledi silent on RPL
Archer said Motsoaledi's deputy, Molefi Sefularo, had promised that the RPL schedules would be withdrawn and 'renegotiated with the professions', particularly in the light of the impending NHI.'Now it appears the whole thing is in doubt and it's very worrying. We've repeatedly asked for an audience with the minister but have not yet had an acknowledgement. I understand he's busy in his new portfolio, but this is critical,' he added.
One thing the private sector could do was to restructure solo practices into group entities, as lawyers and accountants had done to increase cost efficiencies, especially when dealing with the state. Archer said Hogan's 'noises' that the public sector needed fixing before the private sector was tampered with 'were more to our liking, but clearly she didn't have the agreement of the majority of decision makers there.
She was possibly a little too outspoken and was moved for negative, not positive reasons - they wanted her out of health, I think,' said Archer.
Jonathan Bloomberg, Discovery Health's head of Strategy and Risk Management, said Motsoaledi seemed 'very switched on to what the key issues are'. The new health minister had dealt effectively with the OSD doctors' strike while exhibiting an impressive commitment to extensive public engagement and debate. Bloomberg found Motsoaledi's repeated recognition of the impact of NHI and his reassurances that all stakeholders would be involved 'impressive and comforting'.
Professor Denise White, Chairperson of the South African Medical Association (SAMA), said at last doctors were dealing with a health minister 'who's been on the factory floor' and had an inside perspective on the parlous state of the public system.
'He knows what he's dealing with from the ground up. We're not just dealing with a politician looking down,' she said. She agreed with Venter that Motsoaledi faced, as she put it, 'a massive job with enormous challenges'.
'We're 14 years down the line and we've been going backwards for many, many years, but I think he's realistic about things. He'll only be able to deliver if he can depend on the people he has around him and if they have the same grasp and commitment,' she warned. It was 'encouraging' that at last SAMA was receiving acknowledgement of its critical role in the health system after years of being treated 'contemptuously' by Tshabalala-Msimang, who created an 'administrative wall where nobody ever opened the door'.
'Medical associations all over the world enjoy the respect of their governments and are accorded the status of a body that speaks for the profession - I think Motsoaledi grasps this very well.' White said that with Tshabalala-Msimang and her acolytes 'we hit the bottom of the bucket - there's only one way and that's up with the new order. All signals are on green as far as I can see, there's nothing on amber - Manto's autocratic style is out and over,' she added.