The Health Funders Association (HFA) has launched a legal challenge against the National Health Insurance (NHI) Act. The organisation filed its application on the 4th of June in the Pretoria High Court, challenging the Act on constitutional grounds. This marks the sixth legal challenge against the Bill, with others being brought by professional medical associations and other healthcare funding associations.
“South Africa needs a healthcare system that delivers equitable, quality care to all. We fully support that vision,” said Thoneshan Naidoo, the HFA’s chief executive. “However, in its current form, and without private sector collaboration, the NHI Act is fiscally impossible and operationally unworkable, and threatens the stability of the economy and health system, impacting everyone in South Africa.”
Prior to this, the Board of Health Funders had launched its own legal effort to have President Cyril Ramaphosa make public his decision-making process for approving the NHI Bill. So far, he has refused, arguing that opponents would lead to a courtroom “fishing expedition” in search of flawed reasoning.
HFA pointed to research that it had commissioned from economic consultancy Genesis Analytics. The Genesis report showed that unsustainable tax increases were necessary to fund NHI, while also reducing healthcare access for members of medical schemes.
NHI unaffordable even with generous assumptions
Assuming a cost efficiency of 45.5% from state-centralised healthcare funding, R15 432 per capita expenditure would be required, which works out to R941 billion for South Africa’s 61 million. (For comparison, the 2024 budget for US space agency NASA was R440 bn.) This is a 77% increase over SA’s total of R532.2bn for public and private healthcare expenditure in 2022, making healthcare 33% of the budget. Personal income tax rates would rise to over 40% for even the lowest income bracket – more than doubling from 18.5%. The highest income bracket would increase from 45% to 68.4%. Those earning R92 000 a year would have R10 000 less income – if they were already paying for medical aid. If not, that would be R21 000. [One wonders how South Africa can afford this when we cannot easily replace the US$500 million worth of US aid for HIV and other healthcare programmes under PEPFAR. – Ed.]
“Such tax increases are fiscally impossible, particularly given South Africa’s narrow personal income tax base of 7.4 million taxpayers,” the HFA said.
The HFA also argued that the NHI is not a reasonable solution to the constitutional requirement for progressive realisation of the right to healthcare. By making private healthcare only valid for conditions not covered by the NHI, its much-maligned Section 33 infringes on individuals’ healthcare access. Legislative authority is delegated to the Minister of Health, violating the constitutional separation of legislature and executive power. It is fertile ground for tenderpreneurs, as discussed by Jeff Wicks in a News24 article (paywalled). The HFA also notes that the government has admitted in legislation brought by Solidarity that no thorough NHI costing was performed.
Healthcare quality impacted
Even if South Africa were to find the money for NHI between the couch cushions, there have to be skilled people who can provide the services. Nearly 300 000 healthcare professionals would be required, and given the time needed to train new ones, there would be a huge strain.
Worse, analysis shows that the NHI will make things even worse than they currently are. According to Naidoo, “what NHI will do actually is worse than healthcare for the uninsured because combining your medical scheme population, who are older, within a single risk pool, will actually usurp more funds and actually disadvantage the vulnerable.”
But the country is not without options and inherent advantages, Naidoo says, citing the strengths of its private healthcare system. “We can bring to the table the skills, the knowledge and experience on how to build a sustainable funding solution for the entire country. So that’s what we can bring, and we want to make sure we build this country for everyone.”
As the world marks Nurses Day this month, this annual anniversary has shone a sharp spotlight on the realities facing this group of South African heroes and heroines. With many battling burnout, bracing for further staff shortages and trying to find ways to absorb the impact of global funding cuts, Fundi is inviting the country to get behind our nurses and celebrate their daily untold contribution to our local communities.
Recent announcements by the United States to slash foreign aid to global health programmes (including PEPFAR, which funds major HIV initiatives in South Africa) sent shockwaves through our local healthcare sector.
“For nurses already stretched to breaking point, this was yet another blow,” notes Mary Maponya, Fundi Executive Head: Lending. “This isn’t just about money disappearing from a spreadsheet. It’s about support being taken from clinics, treatment delays growing longer and nurses being asked to pick up even more of the slack. We need to acknowledge that nurses are the pulse of public healthcare in South Africa – and that pulse is under pressure.”
Maponya says this is why it was so important for Fundi to find ways to add its voice of thanks and appreciation for nurses this month – including sponsoring and attending Denosa events in Limpopo, Mpumalanga and KwaZulu-Natal. “Department of Health employees make up 16% of our total loan book, with a high proportion of these being nurses,” she explains. “They are a growing sector; continuously investing in their own self-development as a means of deepening their vocations and contribution.”
Fundi’s presence at these events made it possible to engage meaningfully with nurses on the ground; building relationships and understanding how best to continue to provide support around career advancement in particular.
“We are also be running a social media campaign until 23 May where frontline nurses can win free lunch for the week – with Uber Eats delivering it straight to their workplace to lighten the load. Small acts of kindness and appreciation make all the difference,” says Maponya. “And that’s exactly what we’re hoping this campaign will do!”
According to the South African Nursing Council, South Africa has just over 280 000 registered nurses[1], with many nearing retirement age. Meanwhile, nurse emigration is accelerating as we struggle to keep our local nurses employed and supported[2]. “It is estimated that our country will need over 100 000 new nurses by 2030 to maintain even basic healthcare coverage[3],” Maponya explains. “With the bulk of patient care still falling on nurses – from vaccinations and chronic disease management to trauma response – the pressure on these individuals is relentless.”
Amid these systemic failings, one thing is clear however: South Africa’s nurses continue showing up with grace and courage. “This was perhaps the most important take-out from the DENOSA engagement. Our nurses show-up each day – safeguarding the life and health of their patients. These remarkable individuals remain our first line of defence during pandemics, pregnancies, mental health emergencies and more. If we want a healthier South Africa, we must protect the protectors. We need to continue investing in our nurses not just during Nurses Month, but every single day,” she concludes.
The international community must protect global responses to HIV, tuberculosis (TB), and malaria to serve humanity’s collective interests, according to an opinion article published May 14, 2025, in the open-access journalPLOS Global Public Health by Gorik Ooms from the Institute of Tropical Medicine, Belgium, and colleagues.
Within days of starting his second term as President, Donald Trump ended most United States (US) contributions to global health. Global responses to HIV, TB and malaria are not the only programs affected but were particularly dependent on US support. The US withdrawal from global health could result in 3 million additional HIV deaths and 10 million additional HIV infections, 107 000 additional malaria deaths and 15 million additional malaria infections, and 2 million additional TB deaths, all in 2025.
HIV, TB and malaria are global health security threats that require international collective action. The Global Fund to fight AIDS, TB and Malaria (Global Fund) entered its replenishment cycle for 2027–2029, with a target of $18 billion. A failure of this replenishment would make it impossible for many countries to compensate for decreasing US funding and decreasing Global Fund support.
The abrupt end of most US funding for global health comes at a crucial moment for the fight against the three epidemics. For HIV, funding cuts are disrupting treatment and prevention, and increasing morbidity, mortality and infections especially among marginalised groups. The transmission of TB remains high due to insufficient access to treatment, urbanisation and undernutrition. Control of malaria remains elusive due to emerging resistance to treatments, and insecticides, gaps in prevention, and limited access to healthcare.
According to the authors, the reduction of US bilateral aid calls for re-prioritisation and enhanced coordination of the global fights against HIV, TB and malaria. Currently, the Global Fund is uniquely positioned to undertake this endeavour, as it financially supports HIV, TB and malaria programs in most, if not all, countries affected by US spending cuts. This requires a successful replenishment, which seems improbable given uncertainty about the US position and considering the aid spending cuts announced by other high-income countries. Low- and middle-income countries need to step in, which necessitates an overhaul of the Global Fund governance.
The authors outline four action points. First, all countries, regardless of income level, should support the current replenishment of the Global Fund. Second, the replenishment mechanism should move toward agreed and fair assessed contributions, such as 0.01% of the annual gross domestic product of all countries. Third, the Global Fund should commit to overhauling its governance structures to promote equal representation among geographical constituencies. Fourth, the Global Fund should commit to adhere to the Lusaka Agenda, which captures consensus around five key shifts for the long-term evolution of global health initiatives and the wider health ecosystem.
As noted by the authors, these four actions would save essential elements of the global responses to HIV, TB and malaria and set a central and collaborative mechanism for global health security on a path toward the principles of global public investment.
Dr Gorik Ooms adds: “Richer countries still view global health cooperation primarily as aid, from them to poorer countries. They do not seem to realise how this cooperation also protects their own interests. We must not only find enough funding to sustain it; but also rethink how we work together. Through genuine international cooperation between equal partners.”
Co-author Dr Raffaella Ravinetto concludes: “It is not only a matter of keeping life-saving programs alive. It is also a matter of building and maintaining a solid ecosystem, encompassing health infrastructure, policies and human resources, to make quality health care feasible everywhere. Through solidarity we can serve common interests.”
Image Caption: A person holds medications. Limited access to diagnostics and medicines will worsen treatment quality, inducing resistance to antiretrovirals and medicines for infections.
Trade unions, medical associations and universities are raising the alarm that Gauteng budget cuts at the cost of doctors’ take-home pay will have dire consequences for public sector health. Meanwhile, the National Minister of Health has convened a committee to review the future of overtime for state doctors.
Dysfunction in the Gauteng Department of Health hit home hard for many public sector doctors on 29 April when their overtime payments due for the month went unpaid.
The non-payment came without notice and affected medical staff in facilities across the province, according to the South African Medical Association (SAMA). Only by 6 May did some doctors start to see payments reflect in their bank accounts. More payments are expected soon given that, according to the Basic Conditions of Employment Act, the employer has seven days to settle, said SAMA.
But tensions are rising as this payment blunder follows a protracted row over the department’s unilateral decision to cut and change the terms of commuted overtime in the province. Proposals to cut down on commuted overtime come in the light of a very tight provincial health budget. As with most other provincial health departments, Gauteng’s health budget has been shrinking in real terms for several years.
The delayed payments and the ongoing review of cuts and changes to commuted overtime pay has led to threats of protests and legal action. SAMA says they will make civil claims for salaries owed, including for interest and legal costs. Registrars and medical officers at Dr George Mukhari Academic Hospital in Ga-Rankuwa collectively wrote to the hospital giving notice of withdrawal of overtime services until the non-payment issue is completely resolved. By 7 May, the head of anaesthesiology at Sefako Makgatho Health Sciences University wrote to the CEO of George Mukhari Hospital informing him that no anaesthesia services would take place at the hospital starting 8 May, given the decision by registrars and medical officers to down tools outside of regular work hours.
Those from the medical fraternity that Spotlight spoke to have set out a series of concerns. These include resignations; an exodus of doctors, especially specialists from the public sector; plummeting staff morale; negative impacts on the training of doctors as fewer consultants and seniors are available to supervise – which then puts universities’ training accreditations at risk. Ultimately, several sources point out, it is the services offered to the public that suffer.
Committee appointed
By the beginning of April, there appeared to be some walking back by the Gauteng health department of its unilateral cutback proposals after meeting with the South African Medical Association Trade Union (SAMATU). In the same week, a circular was issued announcing that the national health department was conducting a review of its own, instructing provinces to hold off on their plans. Health Minister Dr Aaron Motsoaledi then set up a committee of experts to review certain human resource policies in the public healthcare sector. This includes a review of community service, commuted overtime, remunerative work outside the public service for health professionals, and rural and related allowances.
Commuted overtime is a pre-determined amount of overtime that doctors employed by provincial health departments are allowed to work. The amount is historically decided by hospital management and is based on an employee’s role, seniority, the department they work in and the amount of overtime they are allowed to safely work. It’s a fixed rate of 1.3 times the applicable hourly tariff for a specific work grade.
There are five contract options. A is no overtime worked; B is overtime of between four and eight hours a week; C is overtime between 9 and 12 hours a week; D is overtime between 13 and 20 hours per week; and an option E is where, on approval, a doctor can be authorised to work more than 20 hours of overtime a week.
As a fixed amount, commuted overtime is predictable supplemental income and for many doctors, it amounts to about a third of their take-home pay.
The long rumblings to cut their overtime pay has seen doctors being required to motivate why they should remain on contracts that pay for more overtime hours and junior doctors say they are being pressured to sign option C contracts, which will pay for fewer overtime hours. There are also proposals to change some of the terms relating to overtime, including scrapping overtime payments for doctors who are on call but not physically present at a facility.
Many doctors already exceed the maximum hours of their contracts because of the emergency nature of their work, gross understaffing and backlogs at their hospitals.
Costly, but essential?
The commuted overtime pay model has been contentious for years because it adds up to a sizeable chunk of the healthcare budget. According to a spending review conducted in 2022 on behalf of National Treasury, the country’s health departments spent R6.9 billion on commuted overtime in 2021. This made up about 70% of the total R9.9 billion spent on all types of overtime.
In an editorial published in the South African Medical Journal in April 2025, health sciences academics, associations, and unions slammed the Gauteng health department’s handling of pay issues. They argue that the basic salaries of medical professionals in the public health sector are already much lower than what would be considered fair pay.
“COT [commuted overtime] has long served as a critical mechanism to ensure that doctors are available beyond the standard workday, safeguarding round-the-clock care in the public health system…The abrupt curtailment of this framework risks hollowing out the after-hours safety net, leaving emergency rooms, wards and clinics dangerously under-resourced,” they wrote.
A co-author of the editorial, SAMA CEO Dr Mzulungile Nodikida, told Spotlight: “Medical doctors in South Africa’s public sector are severely underpaid. A study by SAMA has shown that even the annual cost of living adjustments that have been made on the salaries have not matched inflation in the last 5 years. Commuted overtime has had the effect of masking a deficient salary.”
He said the Gauteng health department has shown itself to be an “unreliable employer”, adding that its relationship with doctors remains fractured as a loss of confidence in the department deepens.
“This breach of the most basic employment obligation: timely remuneration, has cascading effects. It jeopardises morale, compromises service delivery, and calls into question the department’s commitment to its workforce. Doctors now operate under a cloud of uncertainty, unsure whether they will receive their salaries at month-end. This anxiety permeates every aspect of the employment relationship, from retention efforts to the willingness to engage in additional responsibilities,” said Nodikida.
View from the wards
Two doctors who spoke to Spotlight independently, and from two different Gauteng hospitals, say the commuted overtime pay disaster is yet another symptom of weak human resources and poor management from the department of health. For them, proposals to cut commuted overtime is the department shirking from addressing the staffing crisis; the need to improve human resources systems; and rooting out corruption, maladministration and wasteful expenditure. Both doctors asked not to be named for fear of reprisals.
Dr A, who is based at Charlotte Maxeke Johannesburg Academic Hospital, said: “Instead of having a system in place to record how many hours each doctor is actually working and what overtime that person should be paid, the department pays everyone this commuted overtime fixed sum….[Y]ou could be a dermatologist or a psychologist and have very few overtime hours or be a surgeon who is doing a lot of overtime but you all get paid the same if you’re on the same contract option,” she said. “But right now, in my career I’m working way more overtime hours than my contract and I’m not being reimbursed for any of it.”
Dr A said the overtime pay cuts and proposed changes will impact her decision to stay in the public sector.
“It used to be the case that you were happy, once specialised, to stay because the overall lump sum of money from your salary and commuted overtime made up a decent pay – not comparable to what you could earn in private – but decent enough to stay,” she said.
She said she feels like doctors are now being under-valued and coming under attack by their own employer. “The message we are getting is that ‘if you’re not happy, there’s the door’ – but what the department doesn’t understand is that you can’t just replace someone with 10 years’ experience or someone who has 30 years’ experience, it has a huge impact,” she said.
“Our patients are suffering; and every day it’s like a game of Survivor. We run multiple clinics in one clinic space at Charlotte Maxeke, but you can’t offer a functioning service like that. It’s noisy, the computers don’t work, and the intercom is going off the whole time.
“The other day, I had a 90-year-old patient have a panic attack in the waiting room. He had been waiting for a while and left his wife, who is blind, in the car. He had to park far from the hospital building because the parking lot from the hospital fire [in April 2021] is still not properly repaired and he was overcome with worry,” she said.
Dr B works at Chris Hani Baragwanath Hospital and he said the debacle over doctors’ overtime pay has pushed him to the edge. He said doctors are already overworked and disheartened from working within a failing system. He sent photos to Spotlight of theatres and wards in darkness as power went off at the Soweto hospital for days at the end of April.
Chris Hani Baragwanath Hospital plunged in darkness after days-long power outage in late April. (Supplied)
He said staff bring in their own toilet paper because they’re told there’s none. Most alarming, he said “doctors are not getting the training and supervision they need” and regularly perform surgeries and procedures without adequate experience and with no supervision.
“They are overwhelmed, overworked and doing way too many overtime hours that they’re not being paid for. Then they go home overtired, eat a pizza and crash, sleep a few hours then do it all over again the next day, and the next day,” he said.
“We, doctors, are literally the ones putting patients’ lives at risk,” he said, adding that he is “surviving on anti-depressants” and has sometimes shut himself away in hospital storerooms crying tears of sheer frustration, exhaustion and exasperation.
Dr B does still count the wins though. It’s days when he clears an impossibly long patient list of children who need procedures done. It’s when he and his colleagues decide to push through to make sure no child’s procedure gets cancelled.
“Those are the good days – they’re just few and far between. And now the department is coming for us by cutting our overtime pay and forcing us to sign contracts to downgrade our overtime pay,” he said.
Resignations and impact on training
Professor Shabir Madhi is dean of the faculty of Health Sciences at the University of Witwatersrand. He said the proposed cuts and freezing of posts and changes to commuted overtime pay has already resulted in resignations of some senior staff at state hospitals.
“If we don’t have the proper consultant staff complement in these hospitals who can provide supervision throughout the day, it compromises our training of specialists as well as of undergraduate students.
“If the Health Professions Council of South Africa were to do an audit and find that there isn’t adequate consultant cover and supervision, they could remove the accreditation of the training programmes offered by the universities.
“The medical schools are completely dependent on the Gauteng Department of Health to retain consultants and other categories of staff, and to ensure that staff are allocated time for supervision and training of future medical doctors, including specialist, as well as other academic activities.
“It means decision-making around cuts to overtime pay need to be cognisant of the overall impact that it would have, and not only in how it would assess budget constraints. This situation needs meaningful and informed decision-making,” he said.
Dr Phuti Ratshabedi, Gauteng chairperson of SAMATU, said the non-payment of commuted overtime pay in April was a slap in the face from the provincial health department as the union had a meeting with the department that month and left with the department agreeing to uphold their contractual agreements to leave contracts terms for commuted overtime pay unchanged at least till the end of March 2026 – the end of the financial year.
“What we saw is that the department will promise one thing and do another. But we will be holding them to what they stated in their own circular or we will look to legal action.
“What we want to see in this review period is that they go after departments [where overtime is not being performed, but being paid for] but leave other departments alone – they cannot put everyone under the same blanket.
“If the government is able to bail out over and over things like Eskom and Transnet, how can they not prioritise healthcare – this sets our country way back and we doctors will no longer be silent about this,” said Ratshabedi.
Spotlight sent questions to the Gauteng health department, including on how the payment delay happened; the number of people affected; how the department is addressing the wide-spread knock-on effects of their proposed commuted overtime cuts; and what amendments they hope will come out of the national review. Despite several reminders, the department did not respond to our questions.
CAPE TOWN, 7 May 2025 | As South Africa pushes forward with new tobacco control legislation, leading global health experts are urging the nation not to overlook a crucial, evidence-based approach that is transforming public health outcomes in countries like Sweden and New Zealand.
At an event hosted today by Quit Like Sweden (QLS) in Cape Town, public health leaders, policymakers, and harm reduction advocates gathered to present a compelling alternative to traditional tobacco control: one that supports adult smokers in transitioning to safer alternatives.
Quit Like Sweden Founder and Director, Suely Castro, said: “For decades, we’ve relied on the same toolbox: bans, taxes, and restrictions. Yet in many countries, smoking rates have stalled. Sweden took a different path—one that empowered smokers with options. The result? A smoking rate of just 5.3% and the lowest tobacco-related death rate in Europe. South Africa deserves the same success story.”
Sweden’s tobacco harm reduction model prioritises the accessibility, acceptability, and affordability of safer alternatives, such as nicotine pouches, snus, and e-cigarettes, while maintaining traditional cessation and prevention efforts. This pragmatic balance has led Sweden to become the first country globally to almost achieve official smoke-free status.
Similarly, New Zealand has halved its smoking prevalence in just five years by supporting vaping and alternative nicotine products as a pathway out of smoking, particularly among vulnerable groups.
Leading international expert Clive Bates, said: “There are two main lessons to take from international experience. First, it is possible to radically reduce smoking and disease by driving out cigarettes with low-risk, smoke-free alternatives like snus, pouches, vapes or heated tobacco. Second, policies that try to stop these developments are prone to harmful unintended consequences such as more smoking, illicit trade or risky workarounds.”
QLS is calling on members of Parliament to ensure the Bill supports adult access to safer alternatives and includes a clear distinction between combustible tobacco and non-combustible nicotine products.
Suely Castro added: “We are not asking South Africa to blindly copy Sweden. But we are urging policymakers to seriously consider what’s working. Lives are on the line. And the evidence could not be clearer.”
About Quit Like Sweden
Quit Like Sweden is a non-profit platform dedicated to helping countries replicate Sweden’s success in reducing smoking-related harm through comprehensive, evidence-based strategies. Events have already taken place in Brazil, Malaysia, Poland, Japan, and Spain—now South Africa joins the growing movement.
Mycobacterium tuberculosis drug susceptibility test. Photo by CDC on Unsplash
By Catherine Tomlinson
Health research in South Africa has been plunged into crisis with the abrupt termination of several large research grants from the US, with more grant terminations expected in the coming days and weeks. Professor Ntobeko Ntusi, head of the South African Medical Research Council, tells Spotlight about efforts to find alternative funding and to preserve the country’s health research capacity.
Health research in South Africa is facing an unprecedented crisis due to the termination of funding from the United States government. Though exact figures are hard to pin down, indications are that more than half of the country’s research funding has in recent years been coming from the US.
Many health research units and researchers that receive funding from the US National Institutes of Health (NIH) have in recent weeks been notified that their grants have been terminated. This funding is being slashed as part of the efforts by US President Donald Trump’s administration to reduce overall federal spending and end spending that does not align with its political priorities.
Specifically, the administration has sought to end spending supporting LGBTQ+ populations and diversity, as well as equity and inclusion. As many grants for HIV research have indicators of race, gender, and sexual orientation in their target populations and descriptions, this area of research has been particularly hard hit by the cuts. There have also been indications that certain countries, including South Africa and China, would specifically be targeted with NIH cuts.
On 7 February, President Donald Trump issued an executive order stating that the US would stop providing assistance to South Africa in part because it passed a law that allowed for the expropriation of land without compensation, and separately because the South African government took Israel to the International Court of Justice on charges of genocide in Gaza.
Prior to the NIH cuts, some local research funded through other US entities such as the US Agency for International Development (USAID), and the Centers for Disease Control and Prevention (CDC) were also terminated.
How much money is at risk?
“In many ways the South African health research landscape has been a victim of its own success, because for decades we have been the largest recipients of both [official development assistance] funding from the US for research [and] also the largest recipients of NIH funding outside of the US,” says president and CEO of the SAMRC Professor Ntobeko Ntusi.
Determining the exact amount of research funds we get from the US is challenging. This is because funding has come from several different US government entities and distributed across various health research organisations. But the bulk of US research funding in South Africa clearly came from the NIH, which is also the largest funder of global health research.
According to Ntusi, in previous years, the NIH invested, on average, US$150 million – or almost R3 billion – into health research in South Africa every year.
By comparison, the SAMRC’s current annual allocation from government is just under R2 billion, according to Ntusi. “Our baseline funding, which is what the national treasury reflects [approximately R850 million], is what flows to us from the [Department of Health],” he says, adding that they also have “huge allocations” from the Department of Science, Technology and Innovation. (Previous Spotlight reporting quoted the R850 million figure from Treasury’s budget documents, and did not take the additional funds into account.)
How is the SAMRC tracking US funding terminations
Ntusi and his colleagues have been trying to get a clearer picture of the exact extent and potential impacts of the cuts.
While some US funding given to research units in South Africa flows through the SAMRC, the bulk goes directly to research units from international research networks, larger studies, and direct grants. Keeping track of all this is not straight-forward, but Ntusi says the SAMRC has quite up to date information on all the terminations of US research awards and grants.
“I’ve been communicating almost daily with the deputy vice-chancellors for research in all the universities, and they send me almost daily updates,” says Ntusi. He says heads of research units are also keeping him informed.
According to him, of the approximately US$150 million in annual NIH funding, “about 40%…goes to investigator-led studies with South Africans either as [principal investigators] or as sub-awardees and then the other 60% [comes from] network studies that have mostly sub-awards in South Africa”.
Figures that Ntusi shared with Spotlight show that large tertiary institutions like the University of the Witwatersrand, the University of Cape Town, and the University of Stellenbosch, could in a worst case scenario lose over R200 million each, while leading research units, like the Desmond Tutu Health Foundation and the Centre for the AIDS Programme of Research in South Africa, could each lose tens of millions. The SAMRC figures indicate that while many grants have already been terminated, there are also a substantial number that have not been terminated.
Where will new money come from?
Ntusi says the SAMRC is coordinating efforts to secure new funding to address the crisis.
“We have been leading a significant fundraising effort, which…is not for the SAMRC, but for the universities who are most affected [and] also other independent research groups,” he says. “As the custodian of health research in the country, we are looking for solutions not just for the SAMRC but for the entire health research ecosystem.”
Ntusi explains that strategically it made more sense to have a coordinated fundraising approach rather than repeating what happened during COVID-19 when various groups competed against each other and approached the same funders.
“Even though the SAMRC is leading much of this effort, there’s collective input from many stakeholders around the country,” he says, noting that his team is in regular communication with the scientific community, the Department of Health, and Department of Science, Technology and Innovation.
The SAMRC is also asking the Independent Philanthropic Association of South Africa, and large international philanthropies for new funding. He says that some individuals and philanthropies have already reached out to the SAMRC to find out how they can anonymously support research endeavours affected by the cuts.
Can government provide additional funds?
Ntusi says that the SAMRC is in discussions with National Treasury about providing additional funds to support health researchers through the funding crisis.
The editors of Spotlight and GroundUp recently called on National Treasury to commit an extra R1 billion a year to the SAMRC to prevent the devastation of health research capacity in the country. They argued that much larger allocations have previously been made to bail out struggling state-owned entities.
Government has over the last decade spent R520 billion bailing out state-owned entities and other state organs.
How will funds raised by the SAMRC be allocated?
One dilemma is that it is unlikely that all the lost funding could be replaced. This means tough decisions might have to be made about which projects are supported.
Ntusi says that the SAMRC has identified four key areas in need of support.
The first is support for post-graduate students. “There’s a large number of postgraduate students…who are on these grants” and “it’s going to be catastrophic if they all lose the opportunity to complete their PhDs,” he says.
Second is supporting young researchers who may have received their first NIH grant and rely entirely on that funding for their work and income, says Ntusi. This group is “really vulnerable [to funding terminations] and we are prioritising [their] support…to ensure that we continue to support the next generation of scientific leadership coming out of this country,” he says.
A third priority is supporting large research groups that are losing multiple sources of funding. These groups need short-term help to finish ongoing projects and to stay afloat while they apply for new grants – usually needing about 9 to 12 months of support, Ntusi explains.
The fourth priority, he says, is to raise funding to ethically end clinical and interventional studies that have lost their funding, and to make sure participants are connected to appropriate healthcare. Protecting participants is an important focus of the fundraising efforts, says Ntusi, especially since many people involved in large HIV and TB studies come from underprivileged communities.
Ultimately, he says they hope to protect health research capacity in the country to enable South African health researchers to continue to play a meaningful and leading role in their respective research fields.
“If you reflect on what I consider to be one of the greatest successes of this country, it’s been this generation of high calibre scientists who lead absolutely seminal work, and we do it across the entire value chain of research,” says Ntusi. “I would like to see…South Africa [continue to] make those meaningful and leading pioneering contributions.”
African countries face a major challenge of dealing with high rates of communicable diseases, such as malaria and HIV/Aids, and rising levels of non-communicable diseases. But the continent’s health systems don’t have the resources to provide accessible and affordable healthcare to address these challenges.
Historically, aid has played a critical role in supporting African health systems. It has funded key areas, including medical research, treatment programmes, healthcare infrastructure and workforce salaries. In 2021, half of sub-Saharan Africa’s countries relied on external financing for more than one-third of their health expenditures.
As aid dwindles, a stark reality emerges: many African governments are unable to achieve universal health coverage or address rising healthcare costs.
The reduction in aid restricts healthcare services and threatens to reverse decades of health progress on the continent. A fundamental shift in healthcare strategy is necessary to address this crisis.
The well-known maxim that “prevention is better than cure” holds not just for health outcomes but also for economic efficiency. It’s much more affordable to prevent diseases than it is to treat them.
As an infectious diseases specialist, I have seen how preventable diseases can put a financial burden on health systems and households.
For instance, each year, there are global economic losses of over US$33 billion due to neglected tropical diseases. Many conditions, such as lymphatic filariasis, often require lifelong care. This places a heavy burden on families and stretches national healthcare systems to their limits.
African nations can cut healthcare costs through disease prevention. This often requires fewer specialist health workers and less expensive interventions.
To navigate financial constraints, African nations must rethink and redesign their healthcare systems.
Three key areas where cost-effective, preventive strategies can work are: improving water, sanitation, and hygiene; expanding vaccination programmes; and making non-communicable disease prevention part of community health services.
A shift in healthcare delivery
Improving water, sanitation, and hygiene infrastructure
Many diseases prevalent in Africa are transmitted through contact with contaminated water and soil. Investing in safe water, sanitation, and hygiene (WASH) infrastructure is an opportunity. This alone can prevent a host of illnesses such as parasitic worms and diarrhoeal diseases. It can also improve infection control and strengthen epidemic and pandemic disease control.
Currently, WASH coverage in Africa remains inadequate. Millions are vulnerable to preventable illnesses. According to the World Health Organization (WHO), in 2020 alone, about 510 000 deaths in Africa could have been prevented with improved water and sanitation. Of these, 377 000 deaths were caused by diarrhoeal diseases.
Unsafe WASH conditions also contribute to secondary health issues, such as under-nutrition and parasitic infections. Around 14% of acute respiratory infections and 10% of the undernutrition disease burden – such as stunting – are linked to unsafe WASH conditions.
By investing in functional WASH infrastructure, African governments can significantly reduce the incidence of these diseases. This will lead to lower healthcare costs and improved public health outcomes.
Local production of relevant vaccines
Vaccination is one of the most cost-effective health interventions available for preventing infection. Immunisation efforts save over four million lives every year across the continent.
There is an urgent need for vaccines against diseases prevalent in Africa whose current control is heavily reliant on aid. Neglected tropical diseases are among them.
Vaccines can also prevent some non-communicable diseases. A prime example is the human papillomavirus (HPV) vaccine, which can prevent up to 85% of cervical cancer cases in Africa.
HPV vaccination is also more cost-effective than treating cervical cancer. In some African countries, the cost per vaccine dose averages just under US$20. Treatment costs can reach up to US$2,500 per patient, as seen in Tanzania.
It is vital to invest in a comprehensive vaccine ecosystem. This includes strengthening local research and building innovation hubs. Regulatory bodies across the continent must also be harmonised and markets created to attract vaccine investment.
Integrating disease prevention into community healthcare services
Historically, African healthcare systems were designed to address communicable diseases, such as tuberculosis and HIV. This left them ill-equipped to handle the rising burden of non-communicable diseases, such as type 2 diabetes and cardiovascular diseases. One cost-effective approach is to integrate the prevention and management of these diseases into existing community health programmes.
Community health workers currently provide low-cost interventions for health issues such as pneumonia and malaria. They can be trained to address non-communicable diseases as well.
In some countries, community health workers are already filling the service gap. Getting them more involved in prevention strategies will strengthen primary healthcare services in Africa. This investment will ultimately reduce the long-term financial burden of treating chronic diseases.
A treatment-over-prevention approach will not be affordable
Current estimates suggest that by 2030, an additional US$371 billion per year – roughly US$58 per person – will be required to provide basic primary healthcare services across Africa.
Adding to the challenge is the rising global cost of healthcare, projected to increase by 10.4% this year alone. This marks the third consecutive year of escalating costs. For Africa, costs also come from population growth and the rising burden of non-communicable diseases.
By shifting focus from treatment to prevention, African nations can make healthcare accessible, equitable and financially sustainable despite the decline in foreign aid.
In a move that will come as a relief for the hundreds of unemployed doctors currently seeking positions within public healthcare, the Department of Health has announced the creation of 1650 new positions for healthcare professionals. The move includes 1200 new positions for doctors – but only 200 for nurses.
Health Minister Dr Aaron Motsoaledi made the announcement at a media briefing on Thursday 10 April.
“We believe we’re in a position to announce today that the council has approved the advertisement of 1200 jobs for doctors, 200 for nurses and 250 for other healthcare professionals,” Motsoaledi stated. This would come with a cost of R1.78 billion – out of a healthcare budget that has not risen in line with inflation.
Jobless doctors picketed earlier this year as more than 1800 were left in limbo without positions – the true number is likely higher. The South African Medical Association (SAMA) had sent an urgent letter to President Cyril Ramaphosa, warning that if the problem was not addressed, doctors would leave for the private sector or emigrate, leading to the collapse of the public healthcare sector.
The road to specialisation had also been made more challenging by the shortage of positions, with junior doctors have been taking unpaid roles. Such unpaid work does not count toward the registrar component of specialisation and largely only serves to bump up the doctor’s CV by, for example, enabling them to apply for diplomas. Hiring freezes also saw GPs unable to move into government positions, and the limited number of registrar positions has also by some accounts become a bottleneck, with no additional registrar positions added for the past 10–15 years.
Regarding the loss of US funding for HIV programmes, he said that there was a buffer of stock for ARVS, and that “no person needing ARVs would lack” those drugs.
But the small number of new nurse positions was not well received. The Democratic Nursing Organisation of South Africa (DENOSA) was particularly unimpressed given the pressure on overburdened nurses.
DENOSA spokesperson Sonia Mabunda-Kaziboni said, “In the face of a nationwide crisis of nurse shortages, this announcement is not only shockingly inadequate but downright insulting to the nursing fraternity.”
Calling it a “slap in the face”, she continued: “The shortage of nurses in South Africa is nothing short of a devastating crisis. The Free State alone faces a 28% vacancy rate, and similar figures are reflected in other provinces such as the Eastern Cape. National projections estimate that South Africa could be short by over 100 000 nurses by 2030 if urgent interventions are not made.”
DENOSA plans to “name and shame” institutions that have become “dangerous to communities” as a result of unresolved poor conditions.
While Australia was busy defending the Pharmaceutical Benefits Scheme against threats from the United States in recent weeks, another issue related to the supply and trade of medicines was flying under the radar.
Buried on page 19 of the Trump’s administration’s allegations of barriers to trade was a single paragraph related to Australia’s access to generic medicines. These are cheaper alternatives to branded medicines that are no longer under patent.
The US is concerned about how much notice their drug companies have that Australia will introduce a generic version of their product. Once a single generic version of a medicine is listed on the PBS, the price drops. The US argues that lack of advance notice is a barrier to trade.
There is pressure for Australia to emulate aspects of the US system, where drug companies can delay generic copies of their medicines by 30 months.
If the US plays hardball on this issue, perhaps in return for other concessions, this could delay Australia’s access to cheaper generic drugs.
It would also mean significant pressure on Australia’s drug budget, as the government could be forced to pay for the more expensive branded versions to ensure supply.
What’s the current process?
Drug companies use patents to protect their intellectual property and prohibit other manufacturers from copying the drug. The standard patent term in Australia is 20 years, but the time a product is protected by patents can be extended in a number of ways. When patents expire, other companies are able to bring generic versions to market.
A generic manufacturer wanting to market its drug in Australia must apply to the Therapeutic Goods Administration (TGA) for regulatory approval. Before approval is granted, the generic company must provide a certificate to the TGA that states either:
a) that the product will not infringe a valid patent, or
b) that it has notified the patent-holder of its intention to market the product.
The certificate can be provided after the TGA has evaluated the generic – before it grants approval.
If the generic company chooses option “a”, the manufacturer of the patented product may not find out the competing product is going to be launched until after the TGA has approved it.
The patent-holder can then apply for a court order to temporarily stop the generic from coming to market, while legal battles are fought over patent-related issues.
However, if the first generic has already launched and been added to the PBS, it triggers an automatic 25% price drop. This affects all versions of the drug, including the patented product.
In Australia, patented drug companies that try to delay generics by taking legal action without good reason can face penalties and be required to pay compensation.
Patented drug companies don’t like this system. They want to know as early as possible that a generic is planning to launch so they can initiate legal action and prevent or delay generic entry and the associated price reductions.
Is Australia’s system consistent with our trade obligations?
Australia introduced its patent notification system at the request of the US, to comply with the Australia-US Free Trade Agreement (AUSFTA). The World Trade Organization doesn’t require patent notification.
The report also mentions US concerns about the potential for penalties and compensation when a patent owner takes legal action against a generic company.
This report reflects long-standing concerns of the US pharmaceutical industry. In March, its drug makers trade association wrote to the US trade representative complaining that “lack of adequate notification” is an unfair trade practice. It argued this creates uncertainty for patent-holders, prevents resolution of patent challenges before generics enter the market, and penalises patented-drug companies for trying to protect their rights.
Medicines Australia, which represents the Australian subsidiaries of many big patented drug makers, echoes these concerns.
What does the US want instead?
The US patent notification system is much more favourable to the patented drug companies than Australia’s.
In the US, the generic company must notify the patented drug company within 20 days of filing an application for approval.
Then, within 45 days of receiving the notification, the patent-holder can ask the regulator to impose a 30-month delay on approval for the generic.
This means there is an automatic 30-month delay on the launch of the generic, unless patents expire in the meantime or the court decides earlier that valid patents aren’t being infringed.
What could happen if Australia bowed to pressure from the US?
Changing Australia’s system to be more like the US would delay generics entering the market in Australia and keep the price of drugs higher for longer.
The quicker generics can be added to the PBS, the less the government pays. When the first generic is listed on the PBS, a 25% price cut is applied to all versions of the product, including the patented version.
Over time, as more generics get added, prices continue to fall. Having plenty of generic competition can eventually result in prices lower than the PBS co-payment, resulting in savings for consumers.
In the longer term, lost savings from timely listing of generics on the PBS would reduce value for money and add cost pressure.
In time, it could also delay savings for consumers from drugs priced below the PBS co-payment.
Both major parties are saying they won’t use the PBS as a bargaining chip in negotiations with the US over tariffs. They also need to resist pressure to slow down access to generic drugs.
The South African Health Products Regulatory Authority (SAHPRA) has joined the Medical Device Single Audit Programme (MDSAP), an international audit programme of medicines and medical device regulators aimed at improving efficiencies in the regulation of medical device manufacturers by engaging in work sharing and collaboration. SAHPRA joins MDSAP as an affiliate member, which expands its ability to monitor the manufacturing of medical devices beyond South Africa’s borders.
The MDSAP membership will result in the improved regulation of medical devices and in-vitro diagnostics (IVDs) as it increases SAHPRA regulatory reach and ensures that SAHPRA can leverage the resources of other regulators that participate in the MDSAP to both audit and monitor adherence to quality standards by medical device manufacturers in several countries globally.
“SAHPRA’s admission into MDSAP signals progress in our strategy to ensure the efficient application of our own resources and those of our peers globally in safeguarding the quality, efficacy and safety of medical devices and in-vitro diagnostics (IVDs) used by the South African public,” says Dr Boitumelo Semete-Makokotlela, SAHPRA Chief Executive Officer.
Dr Semete-Makokotlela says that the admission to MDSAP adds to individual agreements for both monitoring and regulatory reliance that SAHPRA already has in place with several regulators the world over, and would thus improve SAHPRA’s quality assurance abilities and has the potential to increase turnaround times in reviewing and approving key medical devices manufactured elsewhere in the world.
