By Gale Shabangu, Chairperson, Hospital Association of South Africa (HASA)
Recently, President Cyril Ramaphosa made an important decision: to pause the promulgation of the National Health Insurance (NHI) Act until the Constitutional Court has ruled on the pending challenges to Parliament’s role in passing the Act. In doing so, he affirmed that due process must guide reform.
It is a reminder that healthcare reform is not a race to the finish line, but a journey that requires careful pacing, broad consultation and respect for the voices of South Africans. Reform at this scale is like tending a vast garden: every seed must be planted with foresight, every path cleared with care, so that the harvest nourishes all.
Families already feel the strain of rising costs – electricity, food, borrowing – and medical contributions that climb steadily. Yet even in this pressure, there is resilience. South Africans have always found ways to adapt, to share, to build together. Healthcare reform must honour that spirit, ensuring affordability is not a privilege but a shared foundation.
The private healthcare system is a necessary and valuable part of the scaffolding of our healthcare system, sustaining capacity that millions rely on. Unfinished reforms, such as risk equalisation, mandatory membership, and base benefit packages, remain like bridges half‑built. Completing them would stabilise participation and strengthen the entire ecosystem.
If private participation declines, demand does not vanish – it shifts. Public hospitals, already carrying immense responsibility, would feel the weight. Yet here lies the opportunity: to recognise that public and private healthcare are not adversaries but allies. The public sector anchors universal access; the private sector provides funded capacity that absorbs demand and sustains innovation. Together, they form a single ecosystem, each part vital to the whole.
Healthcare reform is about weaving our systems together into a fabric strong enough to carry us all.
As the President recently noted, readiness is central to bringing legislation into effect. Readiness is not bureaucracy – it is the heartbeat of reform. It signals that change must be feasible, not forced; sustainable, not symbolic. That is a hopeful message, because it means reform will be paced by practicality, not politics.
The path forward is clear and promising: complete outstanding reforms in medical schemes, strengthen risk pooling, invest in primary care and prevention, and sequence structural changes responsibly. These steps are not obstacles – they are stepping stones toward a healthier, more equitable South Africa.
Healthcare reform is a national undertaking and a shared responsibility. Government, funders, providers, employers and civil society are all custodians of this commitment. What matters now is how we act, with realism, collaboration and a clear focus on strengthening what already works.
Equitable access to quality healthcare is our shared goal. Achieving it requires evidence, readiness, and respect for complementarity. With stability, sustainability and collaboration as our compass, South Africa can build a healthcare system that is workable and inspiring – a system that reflects the resilience, dignity and hope of its people.
Healthcare requires stewardship. With stability, sustainability, and collaboration guiding reform, South Africa can build a system that works for everyone. And with optimism guiding reform, I believe we can build a system that works for everyone – today, tomorrow and for generations to come.
COHSASA CEO, Jacqui Stewart (left), moderates the panel discussing “Quality in the Public Sector”. From left: Dr Siphiwe Mndaweni, CEO of the Office of Health Standards Compliance (OHSC), Professor Sabelile Tenza, Associate Professor, Patient Safety and Healthcare Quality, North-West University, Professor Sibusiso Zuma, Chair of the Department of Health Studies at UNISA and Dr Arthur Manning, CEO of Rahima Moosa Women and Children’s Hospital.
Strong leadership, functional governance and an honest culture of reporting are among the critical factors needed to improve and sustain quality care in South Africa’s public health sector, experts said during a panel discussion at the Hospital Show Conference hosted by COHSASA in Sandton recently.
The session, moderated by COHSASA CEO Jacqui Stewart, brought together senior voices from regulation, academia and hospital management to unpack the persistent gaps – and opportunities – in public sector healthcare delivery.
Professor Sibusiso Zuma of UNISA set the tone, noting that quality varies widely across public hospitals and is often determined by how effectively leadership teams work together.
“In my experience, the level of care depends on how heads of departments—nursing, pharmacy and clinical leadership , function as a team,” he said. “They need to identify problems and address them collectively. Management must also be visible, regularly engaging with what is happening on the ground.”
Dr Siphiwe Mndaweni, CEO of the Office of Health Standards Compliance (OHSC), reinforced the central role of leadership and governance structures, drawing on inspection findings.
“Where leadership is weak or absent, quality suffers,” she said. “Infrastructure is another major challenge. Many facilities are old, and maintenance budgets are often diverted elsewhere, meaning planned upkeep simply does not happen.”
She added that even basic resources remain a concern. “Without essentials like soap, effective infection prevention and control is impossible.”
Dr Mndaweni also highlighted shortcomings in clinical governance, linking these directly to rising litigation. “Facilities may have clinical committees on paper, but if they are not meeting to interrogate lapses in care, the system fails.”
Security risks, poor community engagement and underutilised strategic plans further compound the problem. “Too often, documents are developed and then filed away. Facilities lose sight of their strategy and have no real understanding of patient satisfaction.”
However, she noted that where leadership is engaged – actively interacting with staff and patients – outcomes improve significantly.
Responding to questions on balancing regulatory compliance with quality improvement, Dr Arthur Manning, CEO of Rahima Moosa Mother and Child Hospital, argued that compliance should be seen as a starting point rather than an endpoint.
“Standards are a benchmark, but they are not the ceiling,” he said. “Our experience shows that it is possible to move beyond them.”
Professor Zuma agreed, cautioning against a compliance-driven mindset that fades once certification is achieved. “Facilities often put in intense effort to meet regulatory requirements, then step back afterwards,” he said. “Quality improvement cannot be a once-off exercise or confined to a single ‘quality person’. It must be everyone’s responsibility.”
He advocated for broader training in Total Quality Management and regular six-monthly audits involving all staff. “Quality must be continuous,” he said.
Professor Sabelile Tenza of North-West University pointed to a deeper cultural issue undermining progress: performative compliance.
“There is a tendency to be compliant on paper rather than in practice,” she said, citing research in which hospitals borrowed equipment to pass inspections, only to return it afterwards.
She described a culture of concealment, where staff hesitate to report shortages or failures. “There is fear of exposing the truth, even to boards that could advocate for improvements,” she said. “If we remove that fear, we can move forward.”
Professor Tenza also raised concerns about the reporting of adverse events, stressing the need to protect healthcare workers. “Clinicians ask why they should report incidents when they see no feedback or improvement,” she said.
She criticised the gap between policy and practice around “Just Culture” frameworks. “We talk about it, but confidentiality is not adequately protected. Without anonymity, reporting systems will not work “The focus should be on the incident, not the individual,” she said. “That is how a learning culture is created.”
Although the National Department of Health has developed free online reporting tools, uptake remains low. Professor Tenza said the system needs to be more user-friendly and accessible via mobile devices, with less duplication between paper and digital processes.
“The focus should be on the incident, not the individual,” she said. “That is how systems learn.”
Dr Mndaweni acknowledged that regulation can be perceived as punitive but stressed that enforcement is a last resort. “The OHSC is designed to support compliance and improvement, not punishment,” she said. “But where there is persistent non-compliance, enforcement becomes necessary—even to the point of revoking a facility’s licence to operate.”
She added that the regulator is repositioning itself to play a more active role in quality improvement, rather than acting solely as an enforcer.
Dr Manning rejected the notion that compliance and quality improvement are competing priorities. “Regulatory standards define the minimum acceptable level of care,” he said. “Meeting them should be business as usual. The real goal is to exceed them – there should be no trade-off.”
Across South Africa, women play a central role in sustaining economic activity. They lead classrooms, staff hospital wards, run small businesses, work in agriculture, build enterprises and manage households. In many communities, they are the primary earners and the primary caregivers.1
In March, as South Africa observes International Women’s Month, recognising women’s contribution also means ensuring that systems are structured to protect their health. Reliable access to early diagnostics remains one of the most practical levers available to support that protection.
When women experience illness, the impact extends well beyond a single diagnosis. Time away from work affects income, productivity and career progression. In informal employment, where many South African women operate without formal protections, illness can immediately reduce household earnings. The economic effects are felt first at the family level, then across communities.
Women make up the majority of South Africa’s health and social services workforce. They also carry a disproportionate share of unpaid care work in households². Globally, UN Women reports that women reinvest up to 90 percent of their income into their families and communities³. That reinvestment strengthens education, nutrition and long-term stability across generations.
Imagine a young nurse, working at a local clinic, earning a mid-level salary. As the sole breadwinner in her home, living month-to-month, she must use the funds available to pay school fees and associated costs for her children. As she also cares for her aged mother, five people rely on her steady income to survive. If she becomes seriously ill for an extended period of time, the effects are potentially catastrophic for her family, and compound pressure on the economy at large.
South Africa continues to carry a high burden of infectious diseases, including tuberculosis⁴ and HIV, while non-communicable diseases such as diabetes and cancer are rising. Cervical cancer remains the second most common cancer among South African women⁵. But when this cancer is detected early, the five-year relative survival rate exceeds 90 percent. That makes it imperative to raise awareness around early detection, as when cervical cancer is diagnosed at an advanced stage, survival drops significantly⁶.
Early and accurate diagnostics protect women’s ability to remain economically active, particularly for preventable illnesses. Early testing enables faster treatment, reduces complications and limits the need for more complex interventions later. In the case of infectious diseases, it also reduces transmission and protects colleagues, families and communities.
South Africa has a strong laboratory foundation to build on. The National Health Laboratory Service operates one of the largest diagnostic networks in the region, supporting large-scale testing every day⁷. Leveraging existing laboratory capacity allows screening and early detection programmes to expand in ways that are sustainable and aligned with national health priorities.
High-performance HPV testing, rapid HIV diagnostics, molecular tuberculosis testing and integrated blood panels are examples of tools that shorten the path from suspicion to confirmation. Reducing diagnostic delays supports workplace continuity and strengthens health system efficiency. In a country focused on improving workforce participation and economic resilience, this connection is direct.
Protecting women’s health strengthens household stability, supports workforce participation and reinforces economic resilience. Prioritising early diagnosis is a clear and measurable way to invest in South Africa’s long-term growth.
It starts at home, with our mothers, sisters and daughters. Let’s keep reminding them, every now and then, to take a moment and consider their own well-being, for them, and for all of us.
To significantly expand access to affordable, quality primary healthcare in underserved communities, the Cipla Foundation’s Sha’p Left initiative has partnered with the FirstRand Empowerment Foundation (FREF). The partnership aims to aggressively scale the cost-effective nurse-driven surgeries in local communities, across the Western Cape, KwaZulu-Natal and Gauteng.
HEALTHCARE CLOSER TO HOME
This collaboration will help to overcome systemic barriers to healthcare, particularly in terms of equitable access for low-income, uninsured individuals. For many people living in peri-urban and rural areas, access to quality primary healthcare services poses a significant challenge. Over-burdened State medical facilities are often congested, resulting in long waiting times for patients.
Sha’p Left is a patient-centred, cost-aware, nurse-driven primary healthcare service, in the heart of local communities. These nurse surgeries are located in easily accessible hubs such as busy taxi ranks to promote ease of access. The greatest benefit of Sha’p Left is that in addition to saving travel time, it helps to empower people both in terms of caring for their health, but also financially: the lack of queues mean that people don’t need to take a full day off work (resulting in a loss of income) to access basic healthcare.
Currently, Sha’p Left serves more than 5 000 patients monthly, with the patient profile comprising a 60% / 40% female / male split. The existing clinics are GMP compliant containerised solutions, as part of environmental sustainability initiatives and lowering overhead costs, solar solutions are being implemented at these clinics.
CHAMPIONING CHANGE
Strengthening community-based primary healthcare supports national health priorities by reducing the burden on State facilities, promotes preventative healthcare and creates an empowering, dignified experience for patients.
The investment by FREF will help Sha’p Left to deploy more nurse surgeries, and these solutions will ultimately help address inequality and reduce poverty as access to quality healthcare is basic human right. The partnership will scale Sha’p Left from 11 to 61 surgeries by the end of 2029.
SUSTAINABLE SOCIAL IMPACT
The business model involves enterprise development in conjunction with qualified, predominantly female clinical nurse practitioners (CNPs) and assists them to establish sustainable, owner-operated clinics in identified communities to provide affordable primary healthcare services.
This fee-for-service model, driven by the “entreprenurses”, provides a dignified and holistic patient experience. The surgeries have dispensing licenses and therefore a consultations includes the necessary medication required, up to Schedule 4 medicines.
The first three nurse surgeries being deployed in 2026, as part of this partnership, are in these areas:
· Senoane (Gauteng)
· KwaNyuswa (KZN)
· Verulam (KZN)
Blending social impact with sustainability creates a blueprint for scaling primary healthcare in South Africa. With FREF’s support, the Sha’p Left model will expand further into communities where access gaps remain widest, ensuring that more South Africans can easily receive the care they need. This investment ensures that good health is not merely a privilege for a select few people, but for all South Africans.
Countries like South Africa benefited in very concrete ways from multilateral forums. Photo by Kindel Media
By Marcus Low
Funding cuts over the last year or so have created a crisis for multilateral health institutions. Which institutions emerge from this crisis, and in what form, will have real consequences for the health of people in South Africa, argues Spotlight editor Marcus Low.
In recent weeks, there has been a glut of articles from global health big-hitters, all concerned with how multilateral health institutions should, or should not be re-designed. These include articles from Philippe Duneton, Executive Director of UNITAID, Sania Nishtar, CEO of GAVI, and one co-authored by, among others, Anders Nordström, a former acting Director-General of the WHO, Helen Clark, a former New Zealand Prime Minister, and Peter Piot, the driving force behind UNAIDS from the mid-90s to 2008.
The immediate cause of all this debate is the stark reality that funding for multilateral health institutions have been cut dramatically in the last year, mainly, but not exclusively, due to the United States’ retreat from such international forums in favour of bilateral agreements. Even before the funding cuts, the financial outlook at entities like the World Health Organization (WHO) and UNAIDS was bleak. Over the last year, it has tipped over into outright crisis.
The WHO has already undertaken drastic organisational restructuring. Last year, a UN document raised the possibility of “sunsetting” UNAIDS by the end of 2026. It is likely that we will see several more organisations shrinking or disappearing altogether in the coming years.
Why does this matter?
The multilateral health institutions we’ve had in recent decades have not been perfect. They were often overly politicised, fraught with power imbalances, and not always capable of responding quickly and effectively to health emergencies.
But even so, it is unequivocally true that when it comes to healthcare, multilateralism has yielded many tangible benefits that are helping keep people alive. In a world where every country stands alone, these benefits will simply fall away.
There are many examples of such benefits. The WHO’s treatment guidelines for diseases like HIV and TB are public goods that are invaluable in many countries – here in South Africa they were particularly important as an antidote to the crackpot science that flourished in the period of state-sponsored AIDS denialism. The sharing of genomics data between countries was critically important at the height of the COVID-19 pandemic. Over an even longer period, the sharing of data on influenza strains has enabled the rational selection of vaccine components for each hemisphere each year. Medicines regulators in different countries increasingly share some of their work in order to speed their processes up and avoid duplication.
This year, a new HIV prevention injection containing the antiretroviral lenacapavir is being rolled out in South Africa and several other countries, largely with the help of the Global Fund, another international entity. A stable supply of low-cost lenacapavir should be available in around a year or two from now, due to market-shaping work done by UNITAID, the Gates Foundation, the Clinton Health Access Initiative, and Wits RHI. Such market-shaping often involves committing ahead of time to purchase certain volumes of a product to incentivise manufacturers to invest in production capacity, thus kick-starting the market for the product.
Then there is the recent history of how rapidly a new antiretroviral medicine called dolutegravir was rolled out in South Africa from 2019 – today over five million people here are taking it. The Geneva-based Medicines Patent Pool (MPP) negotiated licenses that allowed generic competition to start years earlier than would otherwise have been the case. That enabled the low prices and supply security that has facilitated the massive uptake of dolutegravir here and in dozens of other countries.
It is clearly in South Africa’s interest to help keep mechanisms like the above going.
But to reduce the value of these institutions to purely the technical would miss the essence of what animates them in the first place. The reality is that multilateral health institutions have often been at their most effective when people were driven by the need to address urgent health needs, as for example in the early days of UNAIDS. The belief that people’s health matter, no matter who they are, or where they live – essentially a belief in human rights – can make the difference between an ineffectual bureaucracy and a vital health movement. Our current crisis is not only one of technical capacity, but also one where the animating power of human rights-based thinking is being challenged.
How then should we think about redesigning global health?
There are some tensions between fighting to keep what we currently have and embracing big reforms. For example, on the one hand, given the aid cuts of the last year, people have good reason to be concerned about the potential closure of UNAIDS being a precursor to the further unravelling of the global HIV response. On the other hand, there are legitimate questions as to whether UNAIDS is still fit for purpose, given how the HIV epidemic has changed over the last three decades.
One of the most useful contributions in how to think about all this comes from Nordström and his co-authors. They outline four key paradigm shifts that help bring the current moment into focus. Their paper is worth reading in full for the nuances, but here is a brief paraphrasing of the four paradigm shifts:
The first shift is about recognising the fundamental changes underway in the global burden of disease and in demography. In short, while the key threats in the last three decades were the infectious diseases malaria, tuberculosis, and HIV, they are increasingly being overtaken by non-communicable diseases (like diabetes and hypertension) and mental health disorders. This shift is not yet reflected in the architecture of multilateral health institutions.
The second shift relates to the recentring of power from Geneva in Switzerland and New York and Washington in the USA to countries and regions, giving rise to an increasingly multipolar world. “This shift does not imply that multilateral cooperation is obsolete,” write the authors, “however, it requires a clarification of which future functions should be performed at the global level, and which should be performed by national and regional bodies.”
The third shift refers to the growing push to modernise the landscape of global health institutions. The authors write: “Leaders from low-income and middle-income countries have repeatedly critiqued the dearth of systemic support, the inefficiencies of vertical initiatives, and the resource-intensive bureaucratic processes that accompany them”. Considering these external and internal pressures, they argue there is a need to move from a complex and competitive system to a simpler, needs-based, and agile system.
The fourth shift is linked to the declining relative importance of development assistance, coupled with countries’ rising commitments to increase domestic financing for health. Although some international support will remain essential for low-income countries and humanitarian responses, the authors argue that domestic resources must be the engine of a new ecosystem and ways of working together.
All of these shifts are now occurring within the broader geopolitical context of what Canadian Prime Minister Mark Carney recently described as a “rupture in the world order”. He stressed that the great powers have turned their backs on the rules-based world order and have “begun using economic integration as weapons, tariffs as leverage, financial infrastructure as coercion, supply chains as vulnerabilities to be exploited”. This shift can already be seen in the US’s pivot from multilateralism to bilateral health agreements.
As Carney put it: “The multilateral institutions on which the middle powers have relied – the WTO, the UN, the COP – the architecture, the very architecture of collective problem solving are under threat.”
He argues that middle-powers like Canada, and I’d argue South Africa should aspire to be part of this group, should chart a way forward where they are not overly reliant on super powers like the US and China. Avoiding such an over-reliance is of course also an obvious lesson to take from the US’s abrupt cuts to health aid last year.
Maybe a first harsh reality to come to terms with then is that the rupture that is taking place in global geopolitics is also occurring in the world of global health. To think that we can go back to the way the WHO or UNAIDS were twenty years ago, is wishful thinking. The “rupture” might take time to propagate, but it will extend all the way.
What then is to be done?
Carney also makes the point that the rules-based order wasn’t in fact working as well for everyone as we liked to pretend. To a lesser extent, something similar could be said for multilateralism in health. Getting things done was often hard, the politics was often tricky, and when it came to the crunch, say on something like patents on medicines, the US and Europe almost always held sway.
As outlined above, countries like South Africa benefited in very concrete ways from multilateral forums, but somehow those benefits were never widely appreciated. Ultimately, it is telling that so many national governments have failed to put up the money the WHO requires to do its work – even before the current US withdrawal.
Maybe then, to make a reset of multilateral health institutions a success, will require that governments reassess and newly appreciate why it is that we need multilateral health institutions in the first place.
This will require a thorough and honest assessment of what we have gained from these institutions in recent decades. Things like market-shaping, patent pooling, pooled procurement, sharing of genomics and other data, regulatory harmonisation, guideline development, research cooperation, and multilateral fund raising have all been important and will continue to be so. We must make sure that in whatever emerges in the next few years, we have multilateral mechanisms that can deliver in all these areas.
But we will have to accept that those entities might look quite different from what we’ve come to know in recent decades. There will certainly be areas in which we still need global institutions like the WHO, but for some issues we might get more done by working with coalitions of the willing, or collaborating at a regional level – as we’re already seeing with the African Medicines Agency (although South Africa rather inexplicably hasn’t yet ratified the related treaty).
The reality is that apart from governments just not being willing to spend more on health at the moment, the enabling geopolitical substructure that we’ve been relying on for decades has given way. In many respects, this has been a disaster for our common good, but it is also an opportunity to craft new and more fit-for-purpose multilateral health institutions that are animated by a shared commitment to human rights. This is an opportunity that countries like South Africa must grasp.
As Carney put it: “We know the old order is not coming back. We shouldn’t mourn it. Nostalgia is not a strategy, but we believe that from the fracture, we can build something bigger, better, stronger, more just. This is the task of the middle powers, the countries that have the most to lose from a world of fortresses and most to gain from genuine cooperation.”
*Low is the editor of Spotlight.
This article was jointly published with Health Policy Watch, a global health news platform.
Disclosure: The Gates Foundation is mentioned in this article. Spotlight receives funding from the Gates Foundation, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
Universal health coverage cannot succeed with fragmented systems, weak data, and largely symbolic participation. A recent court-ordered pause to NHI implementation offers a chance to build the foundations properly, argue Dr Haseena Majid and Professor Mogie Subban.
Implementation of the NHI Act has been delayed following a High Court order, by agreement between the parties, prohibiting the proclamation or implementation of its provisions until the Constitutional Court rules on challenges related to public participation.
Beyond the legalities, the pause reveals something more consequential. Universal health coverage cannot succeed on fragile administrative foundations.
If the NHI is to deliver equity, efficiency and quality care, the state must first confront the structural weaknesses that continue to shape large parts of South Africa’s health system. These include fragmented governance across national, provincial and local levels that weakens coordination and accountability; persistent shortages of health professionals that leave facilities understaffed and overburdened; and weak information systems that limit the state’s ability to track performance, allocate resources effectively and plan services based on reliable data.
The NHI Act can mandate pooled financing and new purchasing arrangements, but financing reform alone cannot fix fragmented governance, uneven data systems or inconsistent coordination between stakeholders. When reforms are layered onto unstable administrative systems, the result is not transformation but increased risk.
The eye health example
Eye health illustrates this challenge clearly. This is because it depends on coordination across many parts of the health system including clinics, skilled cadres such as optometrists and ophthalmologists, hospitals, NGOs and screening programmes. When these stakeholders do not work together effectively, patients fall through the gaps.
South Africa’s burden of chronic disease is rising, and with it preventable vision loss. The International Diabetes Federation estimates that around 2.3 million people in South Africa aged 20–79 live with diabetes, a condition that can affect the eyes and lead to vision loss and blindness if not detected early. Studies in South Africa have reported high rates of diabetic eye disease, including prevalence estimates of 39% in a tertiary diabetes clinic in Durban and around 25% in primary care settings in Tshwane.
These figures are not simply about eye disease. They reflect gaps in chronic disease coordination, screening coverage and referral systems. When diabetic eye screening is inconsistent, when referral pathways are unclear and when health data are incomplete, preventable vision loss becomes far more likely.
Cataract surgery, one of the most effective medical procedures available, is rightly prioritised. Yet provincial reporting continues to show significant surgical backlogs. While numbers fluctuate, the pattern remains consistent: demand continues to outpace coordinated capacity.
Vision challenges are also increasing as the population ages. A KwaZulu-Natal study reported presbyopia prevalence of 77% among examined adults. As the population grows older, near-vision impairment becomes not only a clinical concern but also one that affects productivity, mobility and independence.
Taken together, diabetes-related eye disease, cataracts and age-related vision decline illustrate a predictable and growing demand for eye-care services. The burden is clear, but the health system response remains uneven.
Only around 6–7% of optometrists practice in the public sector, while the majority work in private urban settings. Across the country, eye-care services are delivered through a mix of public facilities, private practitioners, NGOs, outreach surgical programmes and school screening initiatives. Yet there is no single national picture showing who is providing which services, where those services are located, and how well they are functioning. Government therefore does not consistently have a clear view of which partnerships are active, which communities are overserved or neglected, what equipment is functioning at facilities, or how the workforce is distributed relative to need. This is not a minor administrative gap, instead it is a governance failure with real consequences.
No clear view
Government cannot plan for what it cannot see. Data gaps and poor system visibility are creating blind spots that will paralyse even the best financing reforms. Without clear stakeholder mapping and infrastructure audits, planning becomes reactive. Procurement decisions become distorted and workforce deployment misaligned. Funding reform under the NHI may change how services are purchased, but if the underlying service network remains fragmented, inefficiencies will simply be redistributed.
The consequences extend beyond clinics. Children with uncorrected vision problems struggle at school. Adults with untreated diabetic eye disease risk losing income and economic stability. Older persons waiting for cataract surgery may lose mobility and independence. When health systems fail to coordinate care, the costs are first absorbed by households and later by the state through disability, preventable complications and lost productivity.
The NHI Act aims to improve equity and purchasing efficiency. But efficiency depends on knowing where services exist and where they are missing. Equitable access depends on understanding how infrastructure and human resources are distributed. Quality oversight depends on reliable data that allows performance to be monitored. What the NHI pause ultimately exposes is unfinished work in health-system governance. South Africa does not lack policy ambition. The country is widely recognised for progressive health policy. The challenge lies in fragmented implementation, limited visibility of service networks and uneven coordination across institutions.
A strategic choice
The Department of Health now faces a strategic choice. It can wait for the courts to resolve the legal process, or it can use this moment to strengthen the operational foundations needed for equitable reform.
Eye health presents a practical place to begin. It may not command the urgency of oncology, emergency medicine or infectious disease management, but that is precisely why it offers an opportunity to test workable solutions. Even under the best financing model, sustainable eye care depends on coordinated collaboration between public facilities, private practitioners, NGOs and community networks. A focused national pilot could map eye care services geographically, combining stakeholder mapping with infrastructure audits and workforce distribution analysis. This would strengthen planning in eye health while providing the system visibility that large-scale purchasing reforms like NHI depend on. The efficiency gaps are already known. What is needed now is coordinated implementation. If government can demonstrate that fragmented service environments can be mapped and coordinated within eye health, it will create a practical reform model for other strained areas of the health system.
Universal health coverage will not be secured simply by moving money differently. It will be secured by making the system visible, coordinated and accountable. The current pause has given us more time. What matters now is whether it is used to build the governance foundations that real reform requires.
*Dr Majid is a Postdoctoral Research Fellow at the College of Law and Management Studies, University of KwaZulu-Natal. Professor Subban is Academic Mentor and Public Governance Expert, at the College of Law and Management Studies, University of KwaZulu-Natal.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
Every day in South Africa, 30 people are shot dead. Another 43 are shot and survive. That is more than one person shot every 20 minutes, around the clock, every single day of the year.
Those numbers are staggering, but they don’t begin to convey the cascade of harm that extends beyond the bodies that take the bullets.
Consider this experience of Professor Sithombo Maqungo, head of orthopaedic trauma at Groote Schuur Hospital. A grandmother admitted with a fractured hip is scheduled for urgent surgery on Friday morning. As she is being prepped for theatre, a gunshot victim is rushed in, bleeding out. He dies, but the grandmother’s surgery is postponed as the weekend’s trauma cases overwhelm the unit. By Monday, her condition has deteriorated — blood clots, pressure sores, pneumonia. She dies. Her death certificate will not record “gunshot wound” as the cause. But she is, without question, a victim of gun violence.
This is the ripple effect of gun violence. One shooting does not claim one life. It consumes blood supplies, monopolises theatre time, depletes Intensive Care Unit beds, exhausts healthcare teams, and drives skilled professionals — paramedics, nurses, surgeons — out of a system that can no longer support them.
South Africa’s healthcare system is treating gun violence, it is not preventing it. And that distinction matters enormously.
Young men are the primary victims and perpetrators of gun violence, but women are increasingly killed with guns. After declining, following the Firearms Control Act of 2000, gun-related femicide has surged — rising 84% between 2017 and 2020/21. By 2020/21, firearms accounted for more than one-third of all femicides, the highest proportion recorded.
Failures in firearm oversight and the growth in licensed guns have contributed to this reversal.
South Africa’s own evidence shows that regulation works. When the Act was properly enforced between 2000 and 2010 — guided by a five-pillar strategy that tightened regulations and reduced the availability of firearms — gun deaths halved, from 34 people shot dead daily to 18, while a woman died at the hands of an intimate partner every eight hours rather than every six hours because fewer women were shot and killed.
As oversight weakened through under-resourcing, corruption and policy drift, deaths rose again.
Today, licence applications are 66% higher than in 2016, with a record 166,603 new applications in 2024/25 alone — expanding the pool of legally held guns that leak into criminal hands or are used to commit crimes.
Illegal guns don’t come from nowhere
A common misconception is that tightening firearm laws is pointless because most crime guns are unlicensed. But illegal guns do not appear from nowhere: virtually every firearm in criminal circulation was once legally manufactured and legally owned before it was lost, stolen, or sold into the illegal market. In South Africa, civilians are by far the biggest source of this leakage. Over the past 20 years, civilians have lost or had stolen an average of seven guns for every one lost or stolen by the police, according to South African Police Service annual reports. In 2024/25 alone, civilians reported the loss or theft of 7,895 firearms — 22 a day — and this is almost certainly an underestimate, since some owners do not report losses for fear of being charged with negligence (police reported the loss/ theft of 572 service guns in this time).
Legal guns are also used directly to commit crimes, particularly in domestic violence, where murder-suicides involving licensed firearms are well documented.
Controlling legal gun ownership is not separate from addressing gun crime — it is the primary mechanism for doing so.
The public health approach
A key question in response to South Africa’s gun violence crisis is why gun violence remains outside the core public health frameworks — and what would change if it were treated as the preventable health crisis it is.
A public health approach treats guns the way we treat other products that harm health — like alcohol and tobacco — moving the response upstream from treating wounds to preventing them by tightening controls over availability.
It would give healthcare workers, overwhelmed by the relentless flood of trauma, the ability to recognise that gunshot wounds are not inevitable but a preventable crisis dependent on political will and policy intervention.
It would create concrete opportunities for the health system to play a proactive role in prevention — screening for firearm access during domestic violence consultations to support gun removal from high-risk situations; linking young gunshot victims in surgical wards with gang exit programmes; using admission and forensic pathology data to identify violence hotspots and inform targeted policing.
It would make the true costs of gun violence visible to policymakers and the public — revealing how much is spent managing a preventable crisis on limited resources and overstretched facilities that could instead go towards primary healthcare, cancer treatment, or diabetes care. And crucially, it grounds the debate in evidence rather than ideology — vital in a post-truth world where beliefs, opinions, and hearsay are routinely presented as fact.
This approach would also recognise that firearms are a product sold for profit that harms people’s health. Just as taxes on alcohol and tobacco reflect their social costs and reduce consumption, firearms, ammunition and shooting activities should be subject to equivalent measures. This would generate revenue that could fund the very health services overwhelmed by the consequences of gun violence.
This sharpens the policy response too. South Africa’s Firearms Control Amendment Bill, currently at Nedlac, proposes strengthening limits on who can own firearms, the type and number of firearms and ammunition rounds that can be held, and for which purposes.
Treating gun violence as a public health crisis strengthens the case for these reforms: it positions the Bill not as a security measure but as a health measure, demanding the same urgent political commitment we would expect for any leading cause of preventable death and injury.
International framework
None of this can happen in isolation. South Africa needs international frameworks, evidence, and solidarity — and that is where the World Health Organisation (WHO) comes in.
On 10 February 2026, the Global Coalition for WHO Action on Gun Violence launched with more than 100 organisations across 40 countries, including a range of South African organisations spanning healthcare, child and women’s rights, legal advocacy, violence prevention, and research. The coalition’s formation was accompanied by a stark finding: not one of the World Health Assembly’s 3,200-plus adopted resolutions explicitly mentions firearms.
This is a profound gap. The WHO sets global standards that shape national health policy across 194 member states. When it fails to treat gun violence as a health priority, countries like South Africa are left without the international frameworks, evidence, and technical guidance they need to act.
The WHO has done this before, with other contested, politically sensitive issues — tobacco, HIV/AIDS, alcohol, violence against women — each time moving them from marginal concerns into mainstream public health priorities with measurable results. A resolution on road safety catalysed legislative reform in more than 100 countries. The Framework Convention on Tobacco Control contributed to lasting reductions in global tobacco use. The same is possible for gun violence.
The coalition is calling on the WHO to take ten key actions, including strengthening guidance on gun-related healthcare and supporting countries to use health systems as sites of gun violence prevention. South Africa — with some of the highest rates of gun violence in the world and a documented track record of evidence-based intervention — is uniquely placed not just to support this coalition, but to lead it by sponsoring a World Health Assembly resolution on firearm violence.
Our health professionals are close to breaking point. The surgeon who cannot cope with the relentless toll and resigns — leaving already stretched colleagues even more depleted. The paramedics who quit working in a war zone they never enlisted in. The medical students who leave the profession early, unable to bear the accumulated trauma of what they witness.
Gun violence is not inevitable. It is preventable. Treating it as a public health crisis is the only rational response to the evidence we already have.
Claire Taylor is from Gun Free South Africa, and Dean Peacock is from the Global Coalition for WHO Action. Views expressed are not necessarily those of GroundUp.
South Africa’s public tender framework has long recognised the importance of ensuring reliable, affordable, and uninterrupted access to essential medicines and vaccines, particularly for national immunisation programmes that protect children and vulnerable populations.
While local pharmaceutical manufacturing remains an important national objective, it is equally critical that public procurement decisions prioritise patient access, programme sustainability, and fiscal responsibility, especially in vaccine supply where scale, complexity, and affordability are decisive factors.
Vaccines require scale, specialisation and reliability
Vaccine manufacturing at national immunisation scale requires highly specialised infrastructure, advanced technical capability, strict regulatory compliance, and sustained capital investment. These requirements differ materially from those of many small‑molecule medicines.
“When it comes to vaccines, the overriding priority of the public tender system must be patient access. Scale, affordability, and uninterrupted supply are essential if South Africa is to expand and sustain its national immunisation programmes,” said Simo Masondo, Chairman of the Generic and Biosimilar Medicines Association of South Africa (GBMSA).
Although South Africa has made meaningful progress in strengthening elements of local pharmaceutical capability, vaccine manufacturing readiness varies significantly across product categories, and certain capacities continue to evolve. In this context, national immunisation programme must be supported by a calibrated combination of local and global manufacturing supply, particularly where programme expansion, continuity and affordability are at stake.
A tender system that prioritises supply reliability and scale is essential to ensuring that immunisation program can reach more patients, more consistently and without interruption.
Competitive pricing and demonstrable value for money remain central to the sustainability of South Africa’s public healthcare system. The National Department of Health has consistently emphasised procurement principles that include value for money, open and effective competition, accountability, and equity.
In vaccine procurement, competitive tender outcomes directly enable:
Broader immunisation coverage
Greater reach to children and underserved populations
More efficient use of limited public healthcare resources
Affordability is not a secondary consideration; it is a core enabler of access.
BRICS partnerships as strategic enablers of vaccine access
Trusted international partnerships, particularly within the BRICS ecosystem, play a critical role in supporting South Africa’s vaccine supply objectives. Long‑standing collaborations with partners in countries such as India have consistently demonstrated scale, reliability, regulatory compliance, and significant cost efficiencies in national tenders.
Indian vaccine manufacturers have historically delivered substantial savings to the South African government, in some cases exceeding R2 billion on a single vaccine programme, while supporting the expansion and sustainability of national immunisation coverage.
These partnerships should be viewed not as alternatives to local capability, but as essential enablers of immediate access, affordability, and programme continuity, particularly in vaccine categories where local scale is still developing.
A pragmatic and patient‑centric path forward
“A pragmatic, balanced approach allows South Africa to meet today’s immunisation needs while continuing to build capability over time. This is not a choice between localisation and access; it is about sequencing decisions responsibly so that patients always come first,” Masondo said.
Such an approach ensures:
Reliable and uninterrupted vaccine supply
Expanded immunisation reach for South African children
Responsible stewardship of public healthcare funds
Long‑term programme sustainability
Strengthened international cooperation within BRICS and other trusted partnerships
By prioritising access, affordability, and scale in vaccine procurement, South Africa can protect its immunisation programmes today while continuing to build manufacturing capability over time, without compromising patient outcomes or fiscal sustainability.
The District Health Programme Grant is a mechanism for funding the country’s public health efforts, particularly relating to HIV, TB, and other communicable diseases.
By Russell Rensburg
District managers in South Africa’s public healthcare system currently have to juggle funding from multiple government budget lines, each with different strings attached. To improve district health services, we urgently need to simplify and integrate these funding flows, argues Russell Rensburg.
In his State of the Nation Address this year, for the first time in a long time, President Cyril Ramaphosa focused on the broader determinants of health, delivering the strongest message yet around the importance of prevention.
This included signalling reforms around the taxation and regulation of alcohol as well as announcing broad initiatives to improve child health through good nutrition.
And his announcement that government will be rolling out the HIV prevention injection, lenacapavir, means that South Africa stands at the cusp of a massive healthcare transition. The six-monthly injection will be a game-changer in the country’s ongoing fight against HIV.
His efforts must be applauded.
But to deliver on this, Ramaphosa will need a functioning district healthcare system. The challenge, however, is that the district healthcare system often functions in name, but not in practice. This disconnect is mostly due to how district-level services – and healthcare in general – is funded.
In short, we ask for integrated healthcare services in a system built on siloed funding streams. We task district managers with coordinating care, but the budgets they depend on are split across the provincial equitable share, multiple conditional grants, and hospital-level allocations.
Health is funded from national revenue through two streams: the national department of health and the provincial equitable share. The equitable share, which funds healthcare and education, is calculated using several factors including population size, use of services and potential unmet and future needs. The allocations are unconditional allowing provinces to determine all the allocations relative to provincial realities, cost pressures and needs. With national funding, 85% is transferred to provinces through defined use conditional grants to fund strategic priorities. The challenge is that in recent years these grants have become transfers to provinces with poorly managed conditionalities resulted in fragmented healthcare.
One way to fix these challenges is to consolidate all district health funding — including district hospitals — into a single, nationally coordinated expanded District Health Programme Grant. This reform would align the system with the National Health Act, strengthen accountability, and prepare us for the healthcare transitions ahead.
This shift is not about centralising services. It is about aligning authority with responsibility, and aligning money with the legal design of the health system. Provinces would remain responsible for service delivery. But national government — as required by the Act — would finally have a coherent instrument to guide, monitor, and support the district health system.
A fragmented system
Twenty-three years ago, the National Health Act set out a detailed framework for how healthcare should be structured in the country. Health policy norms and standards are set nationally. Provinces are responsible for coordinating and providing technical and operational support to districts. Crucially, the act locates the delivery of health services within the district health system, which is mandated to plan, coordinate and deliver comprehensive primary healthcare services closest to where people live.
Where the National Health Act falls short, is in providing guidance on how these powers and responsibilities would be financed.
Currently, district health services are funded through three streams:
The provincial equitable share, allocated nationally to each province based on population size and demand for health services. This covers most primary healthcare services and all district hospitals.
The District Health Programme Grant, which focuses on HIV, TB, community outreach, and some primary healthcare enablers.
And thirdly, a patchwork of other conditional grants for training, infrastructure, oncology, and digital systems.
The challenge with this approach is that each of these funding streams has its own rules, reporting requirements, and political histories. None of them were designed to work together.
Making the case for consolidation
Twenty odd years ago, the case for split funding streams made more sense. In the early 2000s, South Africa faced an overwhelming HIV epidemic. We needed targeted programmes, ringfenced funds, and rapid scale-up. Conditional grants was an instrument, that in a specific context, helped save millions of lives. But this instrument has now hardened into permanent architecture. And unfortunately, it is not fit for today’s health challenges.
South Africa is at a critical moment. The population is ageing, rates of non-communicable diseases like diabetes and hypertension are rising, HIV and TB require lifelong, coordinated management, and the pace of technology is rapidly reshaping healthcare.
The system that was built 20 years ago simply cannot carry us through the next 20 years.
At the same time, South Africa’s health budget is tightening. Despite a small increase in last year’s budget, the trend over the last decade or so is clearly toward having to do more with less.
We cannot expect the system to meet these growing demands while the foundational governance and funding architecture is no longer fit for purpose.
How it could work
Under an expanded District Health Programme Grant, national government – as the law mandates – would set the healthcare package, standards, indicators, and information requirements. Provinces would continue to run services, hire staff, manage facilities, and account for performance in line with the provisions of the National Health Act. And districts would finally have a budget that reflects their actual responsibilities.
In simple terms, this means that the expanded district health programme will be structured as a conditional grant. It will be informed by a nationally defined package of district health services, developed in consultation with provinces. Provincial allocations will be informed by strategic priorities and service needs such as essential health services, reproductive, maternal and child health services, as well as infectious diseases and non-communicable diseases. The National Department of Health will be responsible for managing the grant conditions with stronger accountability mechanisms to ensure alignment with strategic aims and constitutional responsibilities. Provinces will continue to control human resources, service delivery networks and district variations. This is what the National Health Act intended.
This is the model used by many countries that have successfully strengthened district health systems: national sets the rules and maintains oversight, while provinces or local governments handle delivery.
As already noted, South Africa does have the legal architecture for this. We just don’t have the financial mechanisms in place to match it.
In practical terms, such reforms will mean that for the first time, a district could budget for clinics, ward‑based outreach teams, HIV and TB services, chronic disease management, district hospitals, laboratory and pharmacy systems, emergency medical services linkages, and digital and information systems.
The artificial lines between primary healthcare and district hospitals would disappear. The system would fund itself as the Act intended, as one. District hospitals would no longer be expected to manage pressures created by primary healthcare gaps they have no control over.
There are several other benefits, such as improved accountability, an easier adaptation to demographic and epidemiological transitions, and more efficient use of limited budgets. These ultimately all develop a realistic pathway to universal health coverage.
A governance correction, not a revolution
There may be concerns that consolidating funding into a single grant means taking power away from provinces. The reality, however, is that this reform would restore coherence, not remove authority.
South Africa has spent decades speaking about equity. This is a practical way to make equity real.
When we underfund the district health system in structure, we undercut the very people who rely on it most. These are rural communities, working class households, and people managing chronic and infectious diseases who require continuity of care, not bureaucratic fragmentation.
A unified District Health Programme Grant will not solve every problem in our health system. But without it, we will continue asking a fragmented system to produce cohesive outcomes, and blaming managers and health workers when it inevitably cannot.
It is time to give the district health system the financial foundation it has always needed. Only then can we build the health system people in South Africa deserve.
*Rensburg is director of the Rural Health Advocacy Project and project director for the TB Accountability Consortium.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
As thousands of cancer patients wait months for diagnostic scans, senior clinicians at Charlotte Maxeke Academic Hospital have questioned a decision by the Gauteng Health Department to override their choice of MRI machine.
In a letter to Gauteng Health Department’s acting chief financial officer, the head of supply chain management at the hospital, Solly Mokgoko, expressed a concern that a recommendation by the head of radiology and the acting clinical director to buy a Philips scanner had been overridden by the Gauteng health department’s central office. The letter is dated 31 October 2025.
Mokgoko said the doctors had preferred the Philips MRI scanner – at a cost of about R27.4-million – on the grounds of “technological advancement, operational sustainability, and clinical research potential”.
However, the department had chosen a machine from Mamello Clinical Solutions at R38.5-million, they said. The room in which the machine will be installed is currently being prepared.
The letter said the Philips unit’s cost “offers reduced lifecycle expenditure due to minimal helium dependency and extended operational uptime”. The Philips scanner used low-maintenance technology, “requiring minimal or no helium top-ups, thereby reducing lifecycle costs and mitigating downtime risks”.
The Mamello-proposed model, by contrast, “relies on traditional cryogenic technology, which entails higher running costs and environmental exposure”, they said.
They said the decision is inconsistent with value-for-money principles set out in the Public Finance Management Act (PFMA) and Treasury regulations.
The purchase of a Chinese MRI scanner from Mamello is part of a R304-million roll-out of eight scanners across Gauteng public hospitals, in which roughly R190-million has been awarded to Mamello Clinical Solutions (five machines) and the remainder to Philips SA.
The Gauteng Department of Health rejected any suggestion of irregularity, saying the purchase was made under a lawful, competitively awarded contract and that both suppliers met the required technical standards.
In this case, the original procurement contract was drawn up by the Limpopo Health Department, with the Gauteng department piggybacking on it.
Clinicians at Charlotte Maxeke who spoke to GroundUp say the procurement shift occurred without adequate consultation and against explicit technical recommendations — allegations the department disputes.
Approximately 2,600 oncology patients are awaiting MRI scans at Charlotte Maxeke alone, with outpatient bookings extending to December 2026. Similar waiting lists exist at Chris Hani Baragwanath Academic Hospital.
The letter said that besides the external patient scans waiting list, there are over 50 inpatients awaiting scans.
One department head said: “How can the hospital order an MRI that’s over R10-million more expensive in an environment where it can’t even provide decent food, [and where there is] widespread cost-cutting and a dire shortage of doctors?” Late last year, the hospital made headlines for shortages of adequate patient meals.
Mamello Clinical Solutions, a private company based in Polokwane, was established in December 2014, trading as Mamello Development until 2019 when it changed its name. Robert Makhubedu, its sole director, was appointed in June 2023 after two previous directors resigned, according to official company registration records.
Makhubedu previously worked as chief radiographer at Charlotte Maxeke Hospital in the early 1990s, then spent more than two decades as director of business development at Tecmed, before joining Mamello Clinical Solutions.
A Gauteng Health Department spokesperson “categorically” denied any irregular, inflated or non-compliant procurement.
He said the MRI acquisitions had been made under a lawful, competitively advertised contract which had been evaluated in line with constitutional, PFMA and Treasury requirements.
Philips Healthcare and Mamello Clinical Solutions had both met minimum safety, functional and performance specifications, he said.
While acknowledging that Charlotte Maxeke clinicians preferred the Philips MRI, the spokesperson said procurement decisions could not be driven by “brand preference or proprietary technology.” He said over the life of the machine the price difference between the two was about R1.07-million, not R11.1-million.
Treasury rules, he said, did not permit sole-supplier selection where multiple bidders meet approved specifications. Multi-supplier models were standard public-sector practice.
Makhubedu pointed out that the tender had not called for a “helium-free” scanner. He attributed the doctors’ complaints to a combination of “brand bias” and hostility towards emerging black-owned companies, compared to multinationals.
“Some black companies awarded these contracts in the past could not relate to the business and clinical profile of the projects,” he said. “The legacy of that is that you have to prove yourself all the time.”
Makhubedu said that provinces tried to strike a procurement balance between emerging and established companies. He said his scanner was in fact R300,000 cheaper than the Philips machine over the life of the machine, and Mamello was capturing market share because of scanner quality and price.
“We believe we were fairly, legally and transparently awarded the contract. And we were cheaper.”
