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Flu Season is Here, with Experts Keeping a Close Eye on New Flu Strain

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Photo by Andrea Piacquadio on Pexels

By Elri Voigt

Many regions in the Northern Hemisphere experienced a slightly earlier start to their flu season, driven in some part by a novel variant of influenza A(H3N2). As our flu season also kicks off slightly earlier than usual, Spotlight reports on the detection of this variant in South Africa and what we might expect from this year’s flu season.

As the mercury slowly starts dropping across the country, so does the risk of picking up flu. For many, this might only mean a few days of illness and discomfort, but for some, especially the elderly, it can be life-threatening.

Despite temperatures throughout most of the country remaining moderate so far, this year’s flu season has started, somewhat ahead of schedule. This is according to the National Institute for Communicable Diseases (NICD) in a press release issued on Wednesday.

What we refer to as flu, is commonly caused by one of two types of influenza viruses, influenza A and influenza B. These two are further typed into different lineages, the most common for influenza A is A(H1N1) and A(H3N2) and for influenza B, the B-Victoria and B-Yamagata.

The Yamagata lineage has not been detected since 2020 and is thought to have gone extinct, said Dr Sibongile Walaza. She is a medical epidemiologist and head of epidemiology at the Centre for Respiratory Disease and Meningitis at the NICD.

A key reason why influenza viruses continue to circulate year after year is how fast they mutate and learn to dodge our immune defenses. These mutations eventually result in different subtypes of lineages that are called clades, within which there can be further sub-clades.

It was a sub-clade of the A(H3N2) virus, known as sub-clade K, that led to the flu season starting earlier than usual in some parts of the Northern Hemisphere. The World Health Organization (WHO) reported that the variant was identified in 2025 and spread fast.

“This [sub-clade] contributed to an earlier start to the influenza season in many countries, with several reporting higher‑than‑usual levels of activity. ‘Subclade K’ accounted for the majority of influenza viruses reported across regions,” the WHO stated in a press release.

Sub-clade K was also responsible for an unusual spike in flu cases in South Africa in October and November 2025. Walaza told Spotlight there weren’t enough flu cases detected to cross the seasonal threshold for an additional flu wave, but the increase so late in the year, outside of the typical flu season, was unusual.

Early start

Usually, South Africa’s flu season starts sometime in April or May and spans the winter months, said Walaza, but it is difficult to predict exactly what will happen in any particular year.

This year’s flu season officially started in the second week of March, according to the NICD’s latest report, albeit at a low transmission level for now. 134 samples were tested between 16 and 22 March. Of those, 12 (9%) tested positive for influenza, 12 (9%) were cases of RSV and 3 (2.2%) tested positive for SARS-CoV-2.

In a rather unusual occurrence, the NICD reported that the start of this year’s RSV season coincided with that of the flu season. RSV refers to respiratory illness caused by the Respiratory syncytial virus. The RSV season usually starts before the flu season, but infections can occur all year round.

“The fact that both the flu and RSV seasons are starting at the same time means clinicians could potentially see a high burden of patients with respiratory illness in medical facilities in the coming weeks,” the NICD said in the press release.

Two potential scenarios

Professor Tulio de Oliveira, the director of the Center for Epidemic Response Innovation at Stellenbosch University, said the reality is that we do not know what to expect for this year’s flu season.

“[At]t the moment, we are working with potentially two different scenarios,” he told Spotlight.

The one scenario is that we may be in for a more extreme flu season, he explained, since last year was an unusually mild season and population immunity against the viruses that cause flu may currently be lower. The other scenario, depending on which flu virus circulates, is that South Africa may have some herd immunity because of the unusual spike in flu cases near the end of last year.

In other words, it all comes down to which flu viruses, and their subtypes end up circulating.

“I think this year we’ll have the three influenza lineages [A(H3N2), A(H1N1)pdm09 and influenza B-Victoria] circulating, but in terms of which one is going to be dominant in the season, it’s difficult to tell in advance,” Walaza said.

What we know about sub-clade K

Based on what we’ve seen so far, it does seem that sub-clade K is more transmissible, but it doesn’t appear to cause more severe disease, according to Walaza. De Oliveira added that sub-clade K has between seven and 10 mutations on the surface protein that allow it to bind to a cell’s receptor and enter the body, making it more infectious.

Whether or not it will be the driver of our flu season this year remains to be seen, but Walaza said that within the sporadic cases of flu detected and sequenced so far this year, most of the cases have been sub-clade K. In an NICD report from March, of the 24 influenza samples that were sequenced between 29 December 2025 and 22 March 2026, 11 were confirmed as being sub-clade K.

(Source: NICD Respiratory Pathogens Report Week 12 2026 report)

Experts will be keeping a close eye on circulating flu viruses with real-time genomic surveillance.

“South Africa is considered to be one of the top virus genomic surveillance places in the world,” De Oliveira said. “[A]t the moment, we don’t see a big reason for concern [about the flu season],” he said. “We do genomic surveillance every week, both with public and private laboratories – and if we see anything unusual, that’s going to be highlighted very promptly.”

Trends seen in previous flu seasons

Overall, in the last ten years, influenza A seems to be the driver of the majority of flu cases in South Africa, said De Oliveira, usually causing a big wave of flu cases at the start of the season. This is usually followed by a smaller wave of influenza B cases. In this time period, the influenza A subtype that dominates during the flu season appears to alternate between A(H1N1) one year and A(H3N2) the following year, but it also doesn’t always follow this pattern.

Zooming in more closely, Walaza said that over the last six years, 2020 and 2021 were outliers, with reduced transmission during 2020 due to the measures taken to curb the spread of the SARS-CoV-2 virus and out of season influenza transmission in 2021. Since 2022, the number of people getting flu every year has returned to roughly similar levels as before 2020.

Last year’s flu season was slightly unusual since it had started in late March, according to Walaza, but wasn’t as intense as some of the previous years as transmission remained at a low threshold level. Flu cases peaked in mid-May and then rose again slightly in October and November.

Data on influenza comes from three sentinel monitoring programmes managed by the NICD, which cover both the public and private healthcare sectors, said Walaza. A sample of healthcare facilities in the public sector and doctors in the private sector are asked to supply swabs taken from people with influenza-like illnesses or respiratory illnesses. Some general practitioners in the private sector are also enrolled in a programme called Viral Watch.

She said that the swabs are sent to the NICD laboratory and tested for the presence of different viruses, including SARS-CoV-2, influenza, RSV, parainfluenza, human metapneumovirus and rhinoviruses. If the samples test positive for flu, the sample is further tested to identify the lineage. This data is included in the weekly reports published on their website.

Members of the public can contribute to flu surveillance through an online web platform called CoughWatch. People are invited to enroll and provide weekly information on whether they have symptoms of flu or other respiratory illnesses. This is aimed at picking up trends among people who aren’t necessarily getting sick enough to go to the doctor or clinic, said Walaza and can hopefully serve as an early warning system for increases in respiratory illnesses, including flu.

CoughWatch has already opened for enrollment this year. (More information can be found here).

Flu vaccination uptake in South Africa remains low

Each year, the WHO releases recommendations on what should be in upcoming flu vaccines for the Northern Hemisphere and then later the Southern Hemisphere, usually announced around six months before the start of the respective flu seasons.

This year’s flu shot’s formulation is a trivalent one, said Walaza meaning it contains inactivated strains of all three influenza strains, including coverage for the A(H3N2) sub-clade K. Because it contains an inactivated virus, the vaccine itself cannot give someone the flu.

The level of protection offered by flu shots vary, but generally it ranges in effectiveness against preventing infection from about 30% to 60%. This means the shot will offer most people protection from severe disease and death, but it won’t necessarily prevent them from getting sick with the flu altogether.

One of the things that makes it difficult to predict effectiveness ahead of time is the possibility that a strain might circulate that is not well covered by the flu shot. De Oliveira said this “mismatch” is what we saw play out in some of the regions in the Northern Hemisphere in their last flu season.

Despite the partial mismatch between the vaccine used in the northern hemisphere and sub-clade K, several surveillance reports from the Northern hemisphere show that the vaccine nevertheless provides some protection against severe flu caused by sub-clade K.

The WHO also recently touched on this, saying that: “While current influenza vaccines help reduce the burden of disease, their effectiveness can vary by season, product, and population group. Protection is limited to one season”. The majority of flu vaccines purchased each year are by upper-middle and high-income countries, the WHO noted.

Usually, South Africa’s National Department of Health procures about 1 million flu shots for the public health sector, said Walaza and sometimes not all these doses are used.

While flu shots are made available each year, the uptake of these shots in the private sector appears to be low. Based on data collected through the NICD’s Viral Watch initiative – last year the uptake of the influenza vaccine in the private sector, among those enrolled in the programme, was only around 3.4%. This is based on data collected from 768 people enrolled, of those, 26 had gotten a flu shot. As far as Spotlight could establish, there currently isn’t any routine publicly available data on uptake in the public sector. One study of around a thousand people aged 65 and older, found that just over 32% of them had gotten the flu jab in 2018.

Spotlight asked the National Department of Health how many flu vaccines were procured for this year’s flu season. A response had not been received by the time of publication.

Low flu vaccine uptake can in part be attributed to South Africa having much milder winters and less severe flu seasons than the Northern Hemisphere, said De Oliveira.

Lack of awareness of the flu vaccine can also play a role, according to Walaza. She encourages more education and efforts by healthcare workers to inform at risk groups of the flu shot and when it will be available.

The flu shot is recommended for people who are at risk of severe disease, including older persons, pregnant women, people who are immunocompromised or with chronic medical conditions, as well as healthcare workers. But anyone aged six months and older can get the shot.

“The influenza vaccine will be available in pharmacies from the first week of April. The early start to the season means that this year, the vaccine is only becoming available as the season is getting started, so members of the public who fall into groups at high risk for severe influenza are urged to get their vaccines as soon as possible,” the NICD press release stated.

The potential of next generation flu vaccines

Earlier this year, the WHO released results from an assessment report on the value of having improved flu vaccines. “If improved, next-generation, or universal influenza vaccines are available and widely used between 2025 and 2050, they could prevent up to [an estimated]18 billion cases of influenza and save up to 6.2 million lives globally,” the report stated.

“This assessment makes clear the potential benefits that improved influenza vaccines could offer across different settings,” said Dr Philipp Lambach, WHO technical lead of the project. “It provides all those working on future influenza vaccine investments, policy development and research priorities a common set of evidence to catalyse vaccine development.”

According to the WHO, as of February 2026, there are 46 next-generation influenza vaccines in clinical development.

Republished from Spotlight under a Creative Commons licence.

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As NHI Stalls, the Real Debate Is About Trade Offs

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ANC President Cyril Ramaphosa, with Minister of Health, Dr Joe Phaahla and his deputy Dr Sibongiseni Dhlomo, during the signing into law of the National Health Insurance Bill. (Photo: @MYANC/Twitter)

By Thoneshan Naidoo

Healthcare funding is always about trade-offs, writes Thoneshan Naidoo, CEO of the Health Funders Association. The hardest question in healthcare is not what we would like to provide, he argues, but what we can provide sustainably, fairly and at scale.

South Africa’s healthcare debate is shifting and perhaps for the first time in years, it is becoming more honest.

With the National Health Insurance (NHI) Act tied up in legal processes and no credible funding pathway emerging from the 2026 Budget, the conversation is moving away from sweeping promises about the future to a more immediate and uncomfortable question. That is how do we fund healthcare today, and what trade-offs are we willing to accept?

At the centre of that reality is a part of the system that is often misunderstood and frequently criticised – medical schemes.

They are often portrayed as profit driven and exclusionary. In reality, they are not for profit, member owned entities built on a simple but powerful principle, social solidarity. Simply put, members pool their contributions so that those who are healthy today help fund the care of those who are sick.

In practice, around 80% of members claim less than they contribute in any given year. Their contributions help fund the care of the 20% who need it most. That is not exploitation. It is the very definition of risk pooling, and it is the same principle that underpins universal health coverage.

But solidarity comes with trade-offs.

Every Rand paid out in benefits in excess of a member’s monthly contributions is funded by other members. That means decisions about what is covered, how much is paid, and when limits apply are not arbitrary. They are the result of difficult choices about what the overall pool can afford.

These trade-offs become most visible in moments of tension, when a claim is limited, a treatment is excluded, or a dispute arises. To the individual, the system can feel uncaring. But at a system level, the alternative, unlimited funding for every possible intervention, is simply not sustainable.

Even prevention, often presented as an obvious solution, is not as straightforward as it seems.

Take colorectal cancer screening. An inexpensive test such as a faecal immunochemical test can help detect disease early. But many false-positive results lead to follow up procedures like colonoscopies, even when no serious condition is ultimately found. At the same time, some cases are still missed and only diagnosed later, when treatment is more complex and more expensive.

The question is not whether prevention is valuable, it is how to fund it at scale in a way that balances early detection, over treatment and cost.

These are not abstract policy debates but are real world funding decisions that affect millions of people.

And they are taking place in a system under pressure.

Medical scheme membership is voluntary, so younger and healthier individuals often delay joining until they need care. This drives up costs for those already in the system. At the same time, schemes are required to cover a comprehensive set of 270 Prescribed Minimum Benefits, which raises the baseline cost of cover.

The result is a system that works well for those inside it but remains out of reach for many.

This is South Africa’s so-called “missing middle” – millions of working people who earn too much to qualify for public support, but too little to afford private cover. They are left exposed, paying out of pocket, and navigating a fragmented system while waiting for reforms that may still be years away.

As the NHI debate continues, this gap can no longer be treated as a future problem. It is a present reality.

The risk is that the debate remains stuck in ideology. That private healthcare is painted as inherently problematic, or that structural reform alone will resolve access challenges.

Neither is true.

Healthcare funding is always about trade-offs. There are no perfect systems, only different ways of balancing access, quality and affordability within finite resources.

If South Africa is serious about expanding access to healthcare, the debate must move beyond rhetoric and toward practical solutions.

These include using spare capacity in private facilities to treat public patients, and allowing medical schemes, through targeted regulatory reform, to offer affordable primary healthcare cover for people who are currently excluded. Done properly, this could unlock access to private healthcare for more than 10 million uninsured South Africans at a cost of as little as R400 per person per month. Combined with existing tax credits, the impact on a family’s take home pay could be close to negligible. By providing access to preventive and primary care through the private sector, they would reduce pressure on overcrowded public facilities and ease waiting times. Importantly, a strong focus on prevention and early intervention would reduce the need for costly hospitalisation over time.

Medical schemes are well placed to deliver these options, given the principles of social solidarity, community rating and cross-subsidisation that underpin their design. This approach is aligned with the Sustainable Development Goals and the core principles of universal health coverage, and could serve as a practical transitional step as South Africa moves towards the full implementation of National Health Insurance.

After all, the hardest question in healthcare is not what we would like to provide. It is what we can provide sustainably, fairly, and at scale.

*Naidoo is CEO of the Health Funders Association, an industry group that represents several medical schemes and medical scheme administrators in South Africa.

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.

Republished from Spotlight under a Creative Commons licence.

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Well Over Three Million People in SA Develop Depression Every Year, Researchers Estimate

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It is estimated that around seven in 10 adults in South Africa have ever had depression at some point in their lifetime. Photo by Alex Green on Pexels

By Marcus Low

Around 3.8 million people in South Africa developed depression in 2024, estimate leading local researchers in a major new modelling study.

The prevalence of depression among people aged 15 and older in South Africa has dropped slightly from an estimated 5.1% in 2002 to 4.5% in 2024. While a decrease, this nevertheless means that over two million people in the country had depression in mid-2024.

When taken as a whole, there were an estimated 3.84 million new episodes of depression in South Africa in 2024. Since some people may have had more than one episode, the number of people who developed depression over the year will be slightly lower.

The estimates are from mathematical modelling published as a preprint earlier in March on medRxiv. While Spotlight doesn’t usually report on studies that haven’t yet been peer-reviewed, we made an exception because the estimates fill an important gap in our understanding of depression in South Africa and because of the stature of the authors. The new modelling drew on several nationally representative surveys of depression conducted in South Africa since 2002.

The researchers estimate that around seven in 10 adults in South Africa have ever had depression at some point in their lifetime.

“Previous studies have suggested that only 10-15% of the population ever experiences depression, but our study suggests a much higher proportion, 70%,” Dr Leigh Johnson, the lead scientist on the study, told Spotlight.

“Most of these people experience a single episode of depression and have no recurrences. The common belief is that depression is a frequently recurring condition, but this is true for only a minority of people who experience depression,” he said. Johnson is from the Centre of Integrated Data and Epidemiological Research at the University of Cape Town (UCT) and is also responsible for Thembisa, the leading mathematical model of HIV in South Africa.

The new modelling also suggests some interesting nuances regarding who is most at risk of depression. In mid-2024, prevalence in women was at 5.3%, well above the estimated 3.6% in men. Older people were significantly more likely to suffer from depression than young people.

Living with HIV has long been known to increase the risk of depression, but the modelling suggests that this effect has weakened over time as HIV treatment became more widely available. In 2010, 7.1% of people with HIV had depression compared to 4.9% in the general population. By 2024, 5.9% of people with HIV had depression, compared to 4.5% of the general population. In other words, the gap decreased from 2.2 percentage points to 1.4.

Increasing, but still very low antidepressant usage

While rates of depression have been relatively stable, the researchers estimate that antidepressant usage rates have almost tripled, from around 1% of the population using antidepressants in 2008, to 2.8% in 2024. In Europe, Australia, Canada, and the United States, rates are between 4% and 16%.

The proportion of women taking antidepressants is more than four times higher than in men – a difference that cannot fully be explained by the higher rates of depression in women. Social factors like stigma are likely playing a role.

The differences between the private and public sectors are stark. Around 11% of medical scheme members are estimated to be taking antidepressants, compared to 0.9% in the rest of the population. “Levels of antidepressant use in the uninsured population are very low, despite a substantially greater prevalence of depression in people of lower socioeconomic status”, the researchers point out.

“Our study shows quite extreme inequality in access to antidepressant treatment in South Africa, with rates of antidepressant use in the private sector being about 12 times those in the public sector. Levels of antidepressant use in the private sector are quite similar to those in high-income countries, but in South Africa’s uninsured population there are major barriers to accessing mental healthcare,” said Johnson.

One such barrier, say the researchers, is regulatory obstacles that prevent nurses from prescribing antidepressants. This problem is made worse by the fact that South Africa has shortages of public sector psychiatrists and medical doctors.

“The study highlights the burden of depression in our country, the vast treatment gap, and stark inequities in access between the public and the private sectors despite on-paper availability of treatments we have known work to mitigate the effects of depression for decades,” the study’s principal investigator Professor Lara Fairall told Spotlight.

“There was a clear call to review regulatory barriers to wider access to antidepressants in the 2023 National Mental Health Policy Framework and Strategic Plan, but it has not been followed by definitive action,” she says.

“Unlocking these barriers requires clarity of mandate by multiple state and para-statal bodies including the National Department of Health, the South African Health Products Regulatory Authority and the South African Nursing Council, but the study is a reminder that failure to do so leaves millions of people vulnerable with desperate consequences for themselves, their families and the economy,” says Fairall who works as a health systems researcher at King’s College London and leads the Knowledge Translation Unit at UCT.

Republished from Spotlight under a Creative Commons licence.

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To Eliminate TB, We Need to Make Testing More Accessible and Affordable

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Tuberculosis bacteria. Credit: CDC

By Yogan Pillay and Gaurang Tanna

New TB tests have massive potential for South Africa’s struggle to get to grips with the age-old disease. Making the most of these new tests will require both ambition and smart implementation, argue Gaurang Tanna and Dr Yogan Pillay.

Every day, more than 140 people die from tuberculosis (TB) in South Africa, yet TB is both preventable and curable. Too many people are tested too late, allowing the disease to spread silently through communities and turning a curable illness into a fatal one.

Unlike most other diseases, anyone can contract TB – the bacteria are airborne and just the act of breathing makes us vulnerable to contracting TB. The risk of TB is higher for people with suppressed immunity, malnutrition, or living with cancer or HIV.

Reducing deaths from TB depends on earlier diagnosis, yet many people are diagnosed late, often after prolonged illness, and only once they reach hospitals with advanced disease. There are some opportunities for improvement. Firstly, we need to address persistent weaknesses in where and how TB tests are offered. Secondly, we need to address delays in care seeking, and missed opportunities for testing within health facilities. Finally, we need to close the operational barriers that impede testing. An added challenge that the TB disease presents is that it is often present without any symptoms.

In recent years, South Africa took important steps to strengthen its TB response and intensified efforts to find people with the TB disease through implementation of Targeted Universal TB Testing (TUTT). TUTT is a strategy that promotes systematic testing among high-TB risk groups, like people living with HIV, household contacts of individuals with TB, and people with previous TB, irrespective of symptoms.

South Africa now conducts approximately 3.6 million TB tests annually, representing a 50% increase compared to pre-COVID pandemic testing. However, we need to scale this up considerably if we are to reach the more than six million people living with HIV currently receiving HIV treatment in South Africa as well as all those with TB symptoms who are often missed at facilities.

The Department of Health has announced a national goal of conducting 5 million TB tests annually. Public-facing dashboards have been implemented to track TB testing and diagnosis, allowing the public to monitor performance across provinces and districts, strengthening transparency and accountability.

Structural barriers to TB testing

Despite strong commitments, TB testing in South Africa continues to face several structural constraints.

First, the cost of molecular diagnostics limits the scale of testing. Current molecular TB tests cost approximately R230 per test.

Second, inefficient clinic workflows reduce testing coverage. In busy primary healthcare facilities, this leads to missed TB testing, contributing to prolonged diagnostic delays during which transmission continues and disease severity worsens.

Third, many patients, especially children and people living with HIV, can’t produce sputum, which current tests require, further reducing testing coverage.

Fourth, people with the highest burden of TB, particularly men, often do not attend government clinics. Men account for a disproportionate share of TB in South Africa but remain underrepresented in testing programmes, contributing to delayed diagnoses and ongoing transmission.

Evolving and strengthening testing capabilities in line with the ambitions of the next phase of TB control in South Africa requires leveraging emerging diagnostic tools and redesigning how TB testing is delivered.

New diagnostic tools create new opportunities

Just recently, the World Health Organization updated its recommendations on TB diagnostics, endorsing the use of near-point-of-care tests and use of tongue swabs for people who cannot produce sputum to expand access to TB diagnostics and improve diagnostic efficiency. These new tools provide an opportunity to rethink how testing is organised across the health system.

Tongue swabs offer a promising alternative sample type, enabling testing among patients who cannot produce sputum. It has also been demonstrated to be more acceptable for patients and providers and is easier to collect in clinics.

At the same time, near-point-of-care molecular platforms (such as Pluslife, a test that has been approved by the South Africa’s health products regulatory body) offer the potential to diagnose TB closer to the patient. It substantially reduces costs, to about one-third the cost of current molecular tests, while demonstrating comparable diagnostic performance for TB, making large-scale expansion of TB testing more accessible and affordable. By delivering results rapidly, within an hour, this technology could enable a test and treat approach. TB testing, diagnosis, and treatment initiation could all happen during a single primary healthcare visit. This would reduce the time to start treatment and limit the number of patients lost between diagnosis and treatment.

Clinic workflows need to be redesigned

Patients presenting with TB symptoms often move through multiple stages of the clinic process – registration, triage, waiting areas, and clinician consultations – before TB testing is considered. Improving TB testing requires services redesign for patient convenience and accessibility, and to be much more systematic. A few simple changes could be introduced.

Firstly,  introduce a fast-track TB queue, allowing individuals to register digitally and drop off samples without completing a full clinic visit.

Secondly, embed TB symptom screening and sample collection at triage or vital-sign stations. Any patient reporting TB symptoms – cough, fever, night sweats, or weight loss – should have a sample collected while waiting to see a clinician.

Thirdly, for people living with HIV,  introduce twin TB testing with annual viral load test (or CD4 for newly diagnosed patients) to systematically test all people living with HIV.

Lastly, we could equip facilities with a near-point-of-care testing platform, like Pluslife, to deliver results before the clinical consultation, allowing TB to be diagnosed rapidly and at lower cost to the health system. It would enable patients to start treatment on the same day.

These approaches could directly address the most persistent diagnostic and linkage gaps in South Africa’s TB programme.

Extending TB testing beyond clinics

New diagnostic platforms also enable TB testing to move beyond government clinics.

A substantial proportion of individuals with TB, particularly men, do not present to clinics and delay seeking care. Near-point-of-care molecular platforms could enable TB testing through alternative delivery channels, including community settings (such as taxi ranks), community pharmacies, workplace clinics, and households through community health worker programmes.

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Expanding testing beyond clinics will help identify TB earlier among populations that remain underserved by current services.

From policy ambition to implementation

South Africa’s progress over the past four years demonstrates that intensified testing strategies such as TUTT can help increase TB diagnosis. Sustaining this momentum will require redesigning primary health care services to fully use these emerging diagnostic tools. Three priorities should guide this transition.

First, TB sample collection workflows in clinics should be redesigned to ensure that every symptomatic and at-risk person is tested for TB.

Second, new diagnostic tools should be deployed, including the use of tongue swabs for people who cannot produce sputum, as well as low cost near-point-of-care molecular tests to simplify testing and treatment initiation pathways.

Third, TB testing should be expanded through alternative delivery channels to reach people who do not routinely access government clinic services, especially men, who are less likely to seek care in these settings.

By aligning ambition and new technologies with service redesign, South Africa can significantly reduce diagnostic delays, decrease deaths due to TB and accelerate progress towards TB elimination.

*Tanna is a senior programme officer for TB, and Dr Pillay is the director of HIV and TB delivery at the Gates Foundation.

Disclosure: 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.

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.

Republished from Spotlight under a Creative Commons licence.

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Categories : Respiratory Diseases VaccinesTags : Leave a comment

The Hunt for a New TB Vaccine: Why We Are Now so Close, and Why it Matters

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Associate Professor Angelique Kany Kany Luabeya speaks about TB vaccine trials and the introduction of TB vaccines in South Africa. (Photo: Supplied)

By Angelique Kany Kany Luabeya

The only tuberculosis vaccine we have is a century old and offers only limited efficacy in children. With leading South African researchers involved in the pivotal clinical trials of three new tuberculosis vaccine candidates, we are on the verge of a major breakthrough, writes Associate Professor Angelique Kany Kany Luabeya.

My uncle died of abdominal TB a few days ago, after facing repeated challenges in getting an accurate diagnosis. For him, the treatment started much too late. To many in his community, my uncle was a respected teacher, a breadwinner, a pillar of support and strength.

In 2026, why are people still dying from a preventable disease that continues to cause unnecessary deaths and hardship?

Why we urgently need a new TB vaccine should be obvious. For the millions who are sick, and for families living with the catastrophic loss of a loved one, the need is painfully clear.

Prior to the emergence of the SARS-CoV-2 virus, TB was the world’s deadliest infectious disease, killing more than 1.5 million people every year. While COVID-19 has since shown an epidemic downturn, TB’s toll remains devastatingly high.

Globally, an estimated 2 billion people are infected with the Mycobacterium tuberculosis that causes TB in humans. In this state, also known as latent TB infection, they do not have TB symptoms and are non-infectious, but the bacteria remain dormant in their bodies. Of these people, about 5 to 10% will go on to develop active TB when their immune system is no longer able to contain the bacteria. This means that they now have TB disease, sometimes without noticeable symptoms, and risks passing it to others. This could be a family member, a friend, or a stranger who happens to be nearby.

TB bacteria have coexisted with humans for millions of years. There is a cure, but treatment alone is not enough to stop transmission. TB mostly affects countries with limited resources because patients struggle to access care or are unable to complete treatment due to side effects or a lack of food to support the rigorous regimen of drugs they must take to cure them. In addition, the rise of multidrug-resistant tuberculosis is now fueling a global health crisis.

In South Africa, recent data from the World Health Organization’s (WHO) Global TB Report indicate progress, with a 57% reduction in new TB cases since 2015. However, TB mortality is still high and is concentrated mainly in poor and vulnerable communities. According to the WHO, TB still claims over 50 000 lives in South Africa every year. The burden is also unevenly distributed, with some geographic areas affected more than others.

A vaccine which prevents TB

Our hopes are now pinned on developing an efficacious vaccine which prevents people from developing TB disease. WHO modelling suggests that a vaccine which prevents most people with latent TB infection from progressing to active disease would have the most rapid impact on the epidemic in high‑burden countries.

The most urgent priorities for protection would be people living with HIV, healthcare workers at risk of workplace exposure, adolescents and young adults who are driving transmission, as well as those with comorbidities such as diabetes that increase their risk of TB diseases and negatively affect treatment outcomes.

The COVID-19 pandemic proved that when human survival is threatened, the scientific community can respond with breathtaking speed, developing multiple effective vaccines in under a year. Sadly, the urgency and resources allocated to finding an effective TB vaccine do not match the scale of its devastation.

For more than a century (since 1921), we have had only one licensed TB jab, which is the bacillus Calmette-Guérin (BCG) vaccine that is given at birth. Despite its limitations in preventing TB that infects the lungs – the main route of transmission – BCG remains a critical tool because it protects millions of babies from more serious forms of TB that can spread through the blood to the brain. But, clearly, the BCG vaccine is not enough.

Hope is on the horizon though, with several novel TB vaccines now in late-stage clinical trials. New vaccines or drugs are evaluated clinically in humans in steps, or phases, for safety, immunogenicity, and efficacy.

  • The most advanced is M72/AS01E (M72 for short), which is an adjuvanted subunit vaccine under development by the Gates Medical Research Institute and GlaxoSmithKline. In a phase 2 trial, this vaccine showed close to 50% efficacy in preventing TB disease in TB-infected people—the first time a vaccine has achieved this level of efficacy. A pivotal phase 3 trial of this vaccine has now completed enrolment of 20 000 volunteers, including 13 000 people in South Africa, with results expected in 2028. Developers typically apply for registration with regulatory authorities after successful phase 3 trials – so this study is the last big hurdle for this vaccine.
  • Another promising candidate is the MTBVAC vaccine, a live, whole, attenuated Mycobacterium tuberculosis vaccine developed by Biofabri, in partnership with the University of Zaragoza and sponsored by the International AIDS Vaccine Initiative. It is in a multi-country phase 2b trial in adults and adolescents and a phase 3 trial in newborns, including in South Africa.
  • BioNTech’s mRNA TB vaccine is also being evaluated in a phase 2a study in South Africa. Funded by BioNTech, this vaccine candidate harnesses mRNA technology, which has proved successful in the COVID-19 response.

Paving the way for acceptance and use

South African researchers are at the forefront of these TB vaccine efforts. Our strengths lie in our robust clinical trial capacity, world-class institutions, commitment to equitable solutions, and regulatory expertise, all of which help accelerate vaccine licensure. As a global policy leader, South Africa co-chairs the Finance and Access Working Group at the WHO TB Vaccine Accelerator Council, advocating for fair distribution and sustainable financing, and has recently co-hosted a vaccine preparedness workshop to position the country for the emergence of late-stage TB vaccines.

But the most important aspect to consider is the vaccine’s acceptability and uptake by a myriad of population groups at risk of TB. We learned from COVID-19 how misinformation can devastate vaccine uptake, leading to unnecessary morbidity and mortality. Confidence in new TB vaccines must be built to maximise impact. The context may be different—TB is an old, well-known enemy that affects people close to us. By involving South African communities in the early stages of vaccine trials, we can ensure their priorities are part of the development agenda.

While we continue to improve TB diagnosis and treatment, the hunt for an effective vaccine continues. After a century of fighting TB with only one vaccine and several antibiotics, we might be on the verge of a breakthrough that could finally shift the trajectory of this ancient and deadly disease.

*Associate Professor Angelique Kany Kany Luabeya is the clinical investigator on the M72 TB vaccine trials being conducted at the South African Tuberculosis Vaccine Initiative based at the University of Cape Town.

Disclosure: The Gates Medical Research Institute mentioned in this article is a non-profit organisation and subsidiary of the Gates Foundation. 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.

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.

Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : HIV NeurologyTags :

Early Treatment Helps Protect the Brains of People Living with HIV

On By ModernMedia
If someone living with HIV is not on antiretroviral therapy, the virus can cause inflammation in, among other places, the brain. Photo by Anna Shvets

By Biénne Huisman

Antiretroviral therapy has shifted HIV from a fatal to a chronic condition. But neuropsychiatrists say it is imperative for people living with the virus to start treatment immediately as the “duration of untreated exposure” may cause irreversible brain damage and impact long-term cognitive health. 

It has been recognised for decades that cognitive impairment is a potential complication of HIV infection. Questions over how likely and how serious this potential complication is have become more urgent over time as the population of people living with HIV ages – ageing after all also increases the risk of cognitive decline.

There were around 1.75 million people over the age of 50 living with HIV in South Africa in 2024, according to Thembisa, the leading mathematical model of HIV in the country. This is just over 20% of the estimated eight million HIV positive people in the country. A study published in the Lancet medical journal also has the number at around 20% in sub-Saharan Africa.

This is a delicate field of enquiry as researchers walk a tightrope to avoid “the burden of double stigma”, while conceptualising the necessary tools to best diagnose brain problems and suitable interventions.

Within as little as two weeks

At Groote Schuur Hospital’s Neuroscience Institute, Professor John Joska, director of the University of Cape Town’s (UCT’s) HIV Mental Health Research Unit, explains that HIV can enter the brain within as little as two weeks after the initial infection – primarily through infected white blood cells, such as lymphocytes. If a person is not on antiretroviral therapy, the virus can cause inflammation in the brain and possibly also tissue damage.

“The brain is a protected compartment,” says Joska. “A theory as to how the virus, which is a protein particle, gets into the brain is through infected lymphocytes. This doesn’t directly infect nerve cells, what we call neurons. It infects other supporting tissues and cells in the brain, causing an inflammation which damages typically the white matter of the brain. Over time, that inflammation can cause loss of neurons, but indirectly.”

While antiretroviral therapy is crucial for clearing and suppressing HIV in all body compartments, including in the brain, he says that it does not reverse damage that occurred before the treatment was started.

“Today, people with HIV are living near normal lifespans,” he says. “The question is, will the fact that they’ve had HIV, with some duration of untreated exposure and potential loss of brain tissue, cause them to be at higher risk than the average person for developing dementias of old age – which really are mainly Alzheimer’s disease or vascular dementia.” It is these longer-term effects that are the main concern when it comes to the impact of HIV on the brain.

Part of the problem is that South Africa not only has an ageing population of people living with HIV, but many of these people would only have started treatment quite long after they contracted the virus. One key reason for this is the South African government’s reluctance to make antiretroviral treatment available in the early 2000s. It has been estimated that those delays resulted in over 300 000 avoidable deaths – they may also be contributing to brain health issues now and in the future.

From efavirenz to dolutegravir

Apart from HIV itself, some of the medicines used to treat the infection have also had an impact on the brain.

In 2019, the standard HIV treatment in South Africa changed from a three-drug combination containing an antiretroviral drug called efavirenz, to a combination containing the drug dolutegravir. This shift had mental health benefits, as evidenced in research lead by Joska’s fellow UCT Neuro-HIV researcher, Associate Professor Sam Nightingale.

Joska says: “The study looked at the period from 2017 to 2020 and the switch from efavirenz to dolutegravir based treatment. It was well known that efavirenz caused, certainly for the first two months, a bunch of psychotropic or psychological issues like nightmares or anxiety, even psychosis for some people. But our findings showed people who switched to dolutegravir actually do very well. They look more like people without HIV after eight months. So dolutegravir has been a huge advantage, not only because it’s robust, but because it’s neuro-protective.”

New models for HIV and cognitive impairment

A shift is underway in how experts are thinking about cognitive impairment in people with HIV. Some neuropsychiatrists, including Joska, are recommending a shift away from the 2007 HIV-Associated Neurocognitive Disorders model, arguing that its cognitive test scores do not adequately account for variables such as education and socioeconomic background, and that it can overdiagnose impairment. The argument is set out in an article, lead-authored by Nightingale, that was published in the journal Nature Reviews Neurology in 2023.

The authors argue that a label of cognitive impairment might cause a “double burden of stigma” for people living with HIV – affecting self-esteem, inciting fear and prompting further discrimination against persons already subject to stigma as it stands. To illustrate the point, they point out how, up until recently, people with HIV in the United Kingdom could not become airline pilots due to concerns over cognitive impairment. However, following a campaign by a pilot living with HIV, the United Kingdom’s Civil Aviation Authority removed the ban in 2022.

Nightingale and his colleagues argue that traditional test scores be used in conjunction with real-life symptoms and medical evidence of brain problems. It introduces the conceptual model of HIV-Associated Brain Injury, which refers specifically to damage caused by the virus. This distinguishes it from other causes of cognitive impairment such as depression, substance abuse, diabetes and cardiovascular disease. As Spotlight previously reported, HIV is also associated with an increased risk of depression, though this is at least partially driven by social factors.

Lower cognitive function associated with late diagnosis

At the 2026 Conference on Retroviruses and Opportunistic Infections hosted in Denver in the United States in late February, these issues were tabled at a discussion titled “When I’m 64: Neurodegeneration, Epigenetic Aging, and Cognition in Older People With HIV.”

Professor John Joska is the director of the University of Cape Town’s HIV Mental Health Research Unit. (Photo: Biénne Huisman/Spotlight)

In his presentation, Professor Alan Winston of Imperial College London, also a member of the International HIV-Cognition Working Group, and a frequent co-author alongside Joska and Nightingale, relayed existing research findings that on average, people living with HIV have lower cognitive function – including memory, attention span and executive function like planning – compared to people who don’t have HIV of the same age. He said that this manifests as an increased risk of lower grade early dementia.

Like Joska, Winston stressed that the most deteriorated cognitive function in people living with HIV is associated with untreated HIV and late HIV diagnosis. He reiterated that starting HIV treatment soon after diagnosis is protective, and that viral suppression is associated with better cognition. In groups of patients with HIV well controlled on dolutegravir-based HIV treatment, cognition appears similar to HIV negative groups, he said.

HIV clinicians need to pay better attention to the brain

In an impassioned presentation, Dr Shibani Mukerji, Associate Professor of Neurology at Harvard Medical School, argued that protecting the brain is an overlooked frontier in effective HIV treatment, and that clinicians need to pay more attention to it.

“By the time patients and clinicians notice cognitive decline – generally and in HIV – the damage to the brain is done and lives are affected negatively. People don’t raise cognitive concerns early enough due to stigma, fear, [and] lack of recognition of the issues. It is seen as ‘just getting old’,” she said.

Mukerji emphasised the need to prioritise brain health. “HIV doctors and treatment programmes are focused, almost exclusively, on viral load as the marker of successful treatment. They may be thinking laterally and consider TB and other infections, maybe cardiovascular disease – but they are definitely not paying enough attention to brain health. HIV doctors aren’t aware enough of brain health issues in people living with HIV, and even when they are, they often don’t feel comfortable diagnosing or managing it, so it is under recognised and under diagnosed.”

The perception that there is no way to manage or treat cognitive decline –generally and in people living with HIV – is wrong, she said, adding that optimising physical, mental and social health is critical for brain health.

“Almost half of dementia risk [in people in general] is linked to preventable causes,” she told conference delegates, along with a slide listing preventable causes including loss of hearing, social isolation, cardiovascular disease and depression.

She explained: “If someone has cognitive decline and for example you improve their hearing – if they have hearing issues – and you work on their social isolation, and treat their vascular disease, and treat their depression, you can see a marked improvement in their cognition.”

Ending her presentation with a twist of humour, Mukerji’s last slide referred to the session’s title, a reference to the Beatles song on aging “When I am 64”. She printed the song’s lyrics: “When I get older, losing my hair, many years from now…”, closing her talk by saying: “It’s okay to stand up and sing, in fact your doctor might prescribe it.”

Categories : Expert Opinion Healthcare Politics and RegulationsTags :

Russell Rensburg | Consolidate the Funding of South Africa’s District Health System: Why Reform can’t Wait

On By ModernMedia
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.

Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : Expert Opinion Healthcare Politics and RegulationsTags :

Inside The Box with Dr Andy Gray | How Medicines Pricing Works in SA and How it Might Change in Future

On By ModernMedia
#InsideTheBox is a column by Dr Andy Gray, a pharmaceutical sciences expert at the University of KwaZulu-Natal and Co-Director of the WHO Collaborating Centre on Pharmaceutical Policy and Evidence Based Practice. (Photo: Supplied)

By Andy Gray

In South Africa, as in many places, pharmaceutical companies are not free to change medicine prices as they wish. In his latest Inside The Box column, Dr Andy Gray unpacks how medicines prices are regulated in the country and considers how this regulatory framework might change.

South Africa’s medicine pricing policies are recognised internationally for their commitment to transparency, but the reality may be different from what exists on paper.

Medicine pricing is a good example of the deficiencies in the National Drug Policy (NDP), which has never been revised since it was first issued in 1996. The original policy document proposed the establishment of a Pricing Committee and committed to “total transparency in the pricing structure of pharmaceutical manufacturers, wholesalers, providers of services, such as dispensers of drugs, as well as private clinics and hospitals”.

Two key proposals were that “the wholesale and retail percentage mark-up system will be replaced with a pricing system based on a fixed professional fee” and “price increases will be regulated”. There was also a commitment to monitoring prices in comparison to those charged in other countries. Finally, there was this statement: “Where the State deems that the retail prices of certain pharmaceuticals are unacceptable and that these pharmaceuticals are essential to the well being of any sector of the population, the State will make them available to the private sector at acquisition cost plus the transaction costs involved.”

Few policies survive an encounter with reality, and opposition, and this document is no exception.

Never the twain shall meet

A cardinal feature of South Africa’s medicine pricing system is the clear separation between the public and private sectors.

In the public sector, the prices paid by the provinces, military and prison services are the result of a tender process. Only medicines registered by the South African Health Products Regulatory Authority (SAHPRA) may be offered in response to a tender call. The National Department of Health makes all tenders publicly accessible and also publishes the resultant tender awards, as well as the Master Health Products List, updated whenever any listing changes. The prices paid therefore reflect the downward influence of the buying power of the state. The tenders include a quantification of anticipated demand over the tender period (usually three years). Prices are also influenced by the number of potential suppliers and therefore the extent of competition in the market.

For some critical, high-volume medicines, such as the first-line antiretrovirals, the tender is split among multiple suppliers, at slightly different prices. Split tenders are intended to ensure security of supply if a contracted supplier is unable to meet demand.

Where the state accounts for most of the quantity sold in the country, it is usually able to attract bids at lower prices than are charged in the private sector. However, in some cases, tenders attract no bids and the state is forced to purchase on quotation. Where a registered medicine is only available from a single supplier, the price paid by the state may be closer to that paid in the private sector. In November 2025, the Director-General of Health published a statement of concern about bid prices exceeding the private sector single exit price (SEP), urging manufacturers to “reflect on their pricing practices”.

Although there are some limited agreements to provide state stock, such as childhood vaccines, to private healthcare providers, the two distribution chains and their pricing remain separate. The private sector cannot access medicines at the same price as the state.

Private sector – not entirely transparent

The Medicines and Related Substances Control Amendment Act, 1997, sought to put in place at least some of what was proposed in the 1996 National Drug Policy. After the multinational pharmaceutical industry withdrew a court challenge to the Act in 2001, and after another Amendment Act, the changes came into effect in 2003, but with the pricing portion delayed until 2004. Further delay followed, with court challenges brought by community and hospital pharmacy groups, leading to an eventual Constitutional Court judgment in 2005. While the basic construct remained in place, the government had to revise the dispensing fee.

The basic construct of the pricing provision, which has been inserted into the Medicines and Related Substances Act, 1965, but is not the responsibility of SAHPRA, relies on what is called the SEP. The SEP is defined as “the only price at which manufacturers shall sell medicines and Scheduled substances to any person other than the State”. In other words, the “exit” refers to the price which is charged by the manufacturer to the final seller such as a pharmacy, hospital or healthcare provider. This is a little different from the more commonly used term of a “factory gate price”, which then allows additions to be made at each step in the distribution chain.

The SEP is the price that the final seller charges to the patient or medical scheme. Final sellers are, however, entitled to a dispensing fee, which is set as a maximum each year and differs between pharmacists and licensed dispensing practitioners. Wholesalers do not add a mark-up to the SEP charged by the manufacturer, but are paid a logistics fee by the manufacturer, as a portion of the exit price.

Crucially, the “single” component refers to the intention that the same price would be paid by all buyers, regardless of the volume of medicine procured. In other words, the private sector cannot use its buying power to exert any pressure on manufacturers’ prices. The Act is prescriptive in this regard: “No person shall supply any medicine, medical device or IVD according to a bonus system, rebate system or any other incentive scheme.” While the application of this section to Schedule 0 medicines, medical devices and in vitro diagnostics has been paused, it still applies to other medicines.

Annually, the Pricing Committee asks for input on two elements: the dispensing fees for pharmacists and dispensing practitioners, and the SEP adjustment (SEPA). The latter is a maximum percentage increase that manufacturers can apply to the SEPs on an annual basis. In some years, exceptional additional SEPAs have been allowed, but they have generally mirrored the consumer price index. The SEPA allowed for 2026 was set at a maximum of 1.47%, compared with 5.25% in 2025. The SEPA mechanism has protected South Africa against the large pharmaceutical price increases that have been seen in other countries. However, the initial launch SEP remains unregulated.

The dispensing fees include a flat amount and a percentage of the SEP, varying across 4 price bands. As the price of the medicine increases, the percentage component decreases. For example, the September 2025 version states that where the SEP of a medicine exceeds R1 530.73, the dispensing fee charged by a pharmacist shall not exceed R270.54 + 5% of the SEP.

A spreadsheet showing all declared SEPs (for registered medicines in Schedules 1 to 6) is publicly accessible on the health department’s website. That site also provides access to various SEPA documents. All final sellers are required to disclose to a buyer what the SEP for a medicine is, and then indicate the dispensing fee charged, which cannot exceed the maximum gazetted each year.

So, what’s not transparent?

The first problem lies with the logistics fee paid to wholesalers by manufacturers. Although there is a column in the SEP spreadsheet that shows a logistics fee, the actual amount paid is known to vary considerably. Importantly, where a final seller, such as a large pharmacy chain, owns its own wholesaler, it can gain additional income from the logistics fee. That component is not disclosed to buyers (patients or medical schemes) – but may influence the seller’s ability to charge less than the maximum dispensing fee.

The Act enables the Minister of Health, in consultation with the Pricing Committee, to “prescribe acceptable and prohibited acts” in relation to bonus systems, rebate systems or other incentive schemes. Despite being published for comment on two occasions, in 2014 and in 2017, no final regulations have been issued. The extent to which co-marketing fees, data fees, shelf fees, formulary listing fees, patient assistance programmes, off-invoice rebates and bonus systems have crept back into the private sector is therefore unknown, as is the quantum of such potentially perverse incentives. Certainly, such revenue streams are not transparent to patients and caregivers.

The enforcement capacity of the health department and Pricing Committee is also questionable. South Africa’s much-vaunted transparent medicine pricing system may conceal many unsavoury elements.

New concerns – failure to declare an SEP

Once SAHPRA has registered a new medicine, the online database is updated. However, SAHPRA does not concern itself with pricing. The holder of the certificate of registration (HCR) can choose to sell the medicine only to the state. However, if the HCR wishes to sell the medicine in the private sector, an SEP has to be declared. Some of the questions asked in the declaration form are interesting, but of dubious legal weight. For example, manufacturers are asked: “The methodology used to determine the SEP and factors that influence the price at which the medicine will be sold.” Even though no external reference pricing system is in place, the prices in other countries are requested. While it is reasonable to ask what the registered indications for the medicine are, as approved by SAHPRA, to demand the “prevalence of the disease or condition as established by the applicant in South Africa” is less reasonable. To date, no SEPs have been declared to be “unacceptable”, as was signalled in the NDP in 1996. Manufacturers thus have a relatively free hand to set their private sector launch prices.

However, two high-profile registrations of HIV drugs by SAHPRA, of cabotegravir by GlaxoSmithKline and of lenacapavir by Gilead, have not been followed by the declaration of an SEP. One contributory reason may be a reluctance to make a price to be charged in an upper middle-income country such as South Africa transparent to the rest of world.

Unregistered medicines imported in terms of section 21 (an application to access an unregistered medicine in circumstances where there is no suitable product registered in South Africa) are not subject to the SEP. In the case of the cystic fibrosis treatments sold by the pharmaceutical company Vertex, a refusal to apply for registration by SAHPRA, thus forcing medical schemes and patients to rely on section 21, has allowed the company to reach agreements with specific medical schemes at undisclosed prices. These medicines are not available to public sector patients.

The unknown unknown

Although the National Health Insurance Fund is expected to be an “active purchaser”, using its buying power to exert downward pressure on prices, bolstered by health technology assessment processes, the exact manner in which the prices of medicines will be determined is unclear.

In particular, how the fund will contract with public and private sector providers to serve beneficiaries in a particular geographical area, given the current clear separation in pricing, is yet to be disclosed. Once NHI is fully implemented, the current tender system will not be tenable. A tender award to a single supplier would immediately make all competitors leave the market. Instead, a reimbursement system, perhaps closer to the reference pricing applied in medical scheme formularies, will be needed. The complexity lies in the period of co-existence of the current public and private sectors and a nascent NHI.

Has the NDP 1996 been implemented?

Although a fixed dispensing fee proved impractical, some elements of the 1996 policy are discernible. Regulated price increases are in place, for instance. Other elements are less clearly implemented, and full transparency remains elusive. There is a need to revisit the entirety of the national medicines policy, not least in relation to how best to deliver access to affordable, quality-assured, essential medicines as part of universal health coverage.

*Dr Gray is a Senior Lecturer at the University of KwaZulu-Natal and Co-Director of the WHO Collaborating Centre on Pharmaceutical Policy and Evidence Based Practice. This is part of a series of columns he is writing for Spotlight.

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.

Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : Healthcare Politics and RegulationsTags :

SA has a “Bogus Doctor” Problem

On By ModernMedia
Under South African law, no one may practise medicine unless they have the proper training and are officially registered. Photo by Usman Yousaf on Unsplash

By Elna Schütz

Bogus medical practitioners threaten the health of patients and undermine trust in doctors. The problem might be growing, but so is the fight against it.

“If you’re in the hands of an unqualified person, you’re as well as dead, and we think it is not fair for the country,” Dr Magome Masike tells Spotlight.

He is the Registrar of the Health Professions Council of South Africa (HPCSA), which is responsible for the registration of medical doctors and other health professionals in South Africa.

The controversy over bogus doctors gained widespread attention in late 2023 when it was discovered that ‘TikTok doctor’ Matthew Lani lied about being a medical doctor. In his videos, Lani was often seen in scrubs and wearing a stethoscope, impersonating a medical doctor. Although he was arrested at Helen Joseph Hospital in Johannesburg, the National Prosecuting Authority eventually decided not to prosecute.

The term bogus doctor has become a shorthand for any medical practitioner who is working without being properly qualified or registered by the HPCSA. In practice, being “bogus” can also apply to physiotherapists, interns, or anyone else practising medicine.

The misrepresentation may include using fraudulent certificates, using another practitioner’s registration, or being suspended or erased from the register. It can involve someone who studied but did not fully qualify, or has not kept up to date with their registration. Masike gives the example of the child of a registered practitioner who decides to take on their parent’s practice after their death without themselves being registered.

It is an ongoing problem. In the beginning of February, the HPCSA says it facilitated the arrest of a woman working at a medical facility in Midrand, north of Johannesburg, allegedly without being correctly registered to practice medicine.

Bogus qualifications are part of the larger problem of healthcare fraud. According to research in a report by risk management services firm D-Finitive, it is estimated that this fraud overall costs African countries more than USD50 billion in 2012. In the South African private sector, that comes to about R22-28 billion a year. The report explains that beyond bogus practitioners, there is a problem with similar fraud, like doctors billing more clients than is realistic, manipulating diagnostic and procedural codes, or deceased doctors billing the government for decades after their death. At times, this type of fraud is reportedly executed by syndicates.

“While the majority of practitioners are honest and committed to patient care, it takes only a small number of bad actors, whether unregistered impostors or credentialed professionals abusing the system, to inflict widespread damage,” says Dr Katlego Mothudi, Managing Director of the Board of Healthcare Funders (BHF).

A substantial problem

Masike says that from March 2024 to February 2025, 49 bogus practitioners were caught and arrested. From April to December 2025, that number was at 17. Even though these numbers do not suggest a year-on-year increase, Masike says that overall, the numbers are increasing.

The HPCSA’s annual report for 2024/2025 shows that 589 investigations into unregistered persons were concluded in the year in question. Over the past five years, 3 708 complaints were received.

The majority of bogus practitioners who have been caught were operating in economic hubs of the Western Cape, Gauteng, and KwaZulu-Natal, Masike says. “Bogus people want money, so they go where there’s money,” he explains. However, while the trend tends urban, he says rural communities also fall prey to scammers.

“A notable pattern is that many of these individuals use or forge the details of legitimately registered practitioners,” Masike says.

It is, of course, unclear how many unlicensed practitioners are not yet caught. “We can tell you the problem is bigger than we think,” Masike says. The problem, he says, is sector-wide and stretches across different health professions, with most of these illegal practices occurring in the private sector. Masike adds that bogus doctors often work with a network of others, for example, those who supply unregistered or fake medicines.

Mothudi also says that the problem is growing. “Medical schemes are seeing a rise in suspicious provider activity picked up through claims analysis and credential verification processes,” he says. This may include practitioners misrepresenting their registration status, practising outside their approved scope, or using the registration details of legitimate practitioners to submit claims.

Risk to patients

Catching and prosecuting bogus practitioners is crucial because they can pose a direct danger to unsuspecting patients. “Unregistered medical doctors, like other health professionals, pose severe risks to patients, including serious physical harm, injury, and misdiagnosis which may lead to death, due to their lack of necessary training, ethical standards and relevant qualifications,” warns Foster Mohale, the spokesperson for the National Department of Health.

Dr Zanele Bikitsha, National Vice Chairperson of the South African Medical Association, cautions that if bogus doctors are performing procedures, it will likely be in settings that are not appropriate or sterile.

“They’re not going to go to a registered facility, because they know they’ll be caught, so this puts patients in danger as well.”

While some operate on a cash basis, Mothudi says that submitting claims to medical schemes is attractive because it allows for much larger and repeatable payouts. “In some cases, bogus practitioners submit claims using stolen, borrowed or fraudulently obtained practice numbers belonging to legitimately registered healthcare professionals,” he says. “In other instances, they collude with registered providers who allow their credentials to be misused in exchange for payment.”

Knowing the signs

While the HPCSA undertakes compliance inspections, there are some clear signs that might help the public spot a bogus practitioner. Firstly, it is a legal requirement to have registration information easily visible in a practitioner’s practice and on the letterhead of documents or prescription notes.

Members of the public can also look up a doctor’s credentials. All registered practitioners should be listed in the HPCSA’s digital register online, which is publicly searchable. With as little as the practitioner’s surname, the system lets users search for registered practitioners.

Masike points out that a trained doctor tends to take an extensive medical history and make a systemic or wide-reaching inquiry. He recommends that patients look out for how doctors speak and whether they use and are able to explain medical terminology.

Complaints can be filed with the HPCSA’s Inspectorate, including anonymously. Their call centre is at 0123389300/1 and they can be e-mailed at office@hpcsa.co.za. Suspicious practitioners may also be reported to hospitals, the Department of Health, SAMA or other medical organisations.

Processing the problem

Complaints typically lead to an investigation by the HPCSA Inspectorate, which works together with other entities, such as the South African Health Products Regulatory Authority (SAHPRA), the Office of Health Standards Compliance, the Special Investigating Unit (SIU), and the South African Police Service.

Masike explains that the investigation tends to lead to a clandestine operation and involves the police arresting the suspects. He adds that police recently assigned specific staff members to focus on these cases. He says that once the case goes to court, there is a conviction rate of around 77%, although this may have changed. “Many of the cases from 2023 to 2025 remain before the courts, and therefore updated conviction statistics are not yet available.”

Practising medicine without proper training and registration is in contravention of Section 17(1) of the Health Professions Act, 56 of 1974. Typical sentences for such fraud include fines, such as R12 000, or around two years imprisonment. In one 2017 case, a man who had treated almost a thousand patients over six years was sentenced to 20 years’ imprisonment by the Mahikeng High Court in the North West.

Bikitsha says there are other systemic changes that could help catch the problem earlier on. “If you are still paper-based, you are at risk,” she says, referring to the way that hospitals and institutes tend to verify the qualifications of most interns, locums and medical practitioners. She argues that upgrading to biometrics and digital systems would decrease the risk of fraud.

Another step forward is simply to increase public awareness and education, so that patients know the risks.

Masike concurs. “We need society to stand up to this,” he says. “We need a participating community to get rid of this malaise, otherwise it will continue forever.”

Republished from Spotlight under a Creative Commons licence.

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Categories : Hospitals IT in HealthcareTags :

How WhatsApp is Being Used to Train Healthcare Workers

On By ModernMedia
Photo by Thirdman

By Sue Segar

As HIV, TB and other treatments are updated in our public healthcare system, it is critical that healthcare workers and counsellors stay on top of the latest developments. One innovative programme makes use of short lessons delivered over WhatsApp to provide such training.

Over her years working as an information pharmacist at the University of Cape Town’s Medicines Information Centre (MIC), Briony Chisholm noted that many health workers in rural clinics face difficulties accessing training in crucial aspects of their work.

“The lack of easy access to training was in areas where it was really needed, such as the HIV (treatment) guidelines that are constantly being updated,” says Chisholm. “It’s not enough to have training sessions when new guidelines come out; you ideally should be training all the time.”

Drug-drug interactions

At the end of 2019, government introduced new standard first-line HIV treatment that includes an antiretroviral medicine called dolutegravir. As we previously reported, by 2023 around 4.7 million people in South Africa were taking dolutegravir-based treatment.

But the introduction of a new medicine in the public healthcare system, especially at this scale, is rarely straight-forward.

“Dolutegravir is considered as a ‘wonder child’ in ARV treatment, because it provides a high barrier to resistance, is easier to take, and has far fewer side effects than older ARVs. However, it also has interactions with other key drugs, particularly those used for the treatment of TB, diabetes and some anti-epileptic medications,” she says.

Through numerous queries received on the MIC’s National HIV and TB Healthcare Worker Hotline, Chisholm and her colleagues became aware that some healthcare workers were struggling with managing drug interactions. “Some healthcare workers didn’t know about these interactions; others knew about them but not how to deal with them. For example, if a patient is on the TB drug rifampicin, but also needs to take dolutegravir, there’s a need to adjust the dose of dolutegravir. Similarly, adjustments are needed with the diabetes medicine, metformin.”

Chisholm now lives in the Eastern Cape village of Nieu Bethesda. When dolutegravir was introduced, she had just completed her part-time post-graduate Diploma in HIV and TB management through UCT and signed up for her Masters. She and a colleague had, in 2016, done a road trip to about 200 clinics in seven provinces to promote the MIC’s Hotline.

“We saw that most South African healthcare workers are dedicated and keen to learn. You hear all this terrible news about health and corruption, and then you go to these clinics which are ticking along under sometimes difficult conditions, doing amazing work. It’s inspiring!”

A key realisation was the challenges experienced by health workers at these rural clinics to access much-needed training.

“Getting nurses to a central point for training and the need for transport, accommodation and food, as well as having them absent from the clinic for anything between one and five days, is challenging. It’s expensive and involves a great deal of organising,” says Chisholm.

Doing the research

Chisholm then started conducting research on what healthcare workers know about dolutegravir-related drug interactions. Her study, published in 2022, found that about 70 percent of respondents understood that dolutegravir interacts with other drugs, but there were gaps in people’s knowledge of specific interactions and the dosing changes needed to manage those interactions.

The study found that access to guidelines and training were positively associated with knowledge of drug-drug interactions. “There was a clear indication that we needed more accessible training,” Chisholm says.

“The Department of Health offers online training through live webinars, and recordings of these, but they are often one or two hours long. Nurses in busy clinics don’t necessarily have this time to sit through training sessions.”

Testing the efficacy of short training sessions

Chisholm then designed a project to test the efficacy of short training sessions focusing on teaching one or two learning points from the national guidelines in ten to fifteen-minute live lessons using WhatsApp.

“I thought, ‘we’re in a country where not everyone has access to big computer screens, but they all have a cell phone and use WhatsApp – so let’s go as simple as we can’,” she says. “The idea was not to teach the entire set of guidelines but to pick out important parts of them and ensure that if something changes in the guidelines, you get it out to people, quickly.”

Chisholm tested the feasibility of WhatsApp-based microlearning with health workers and counsellors at 50 clinics around Nieu Bethesda. “I ran a range of short case-based lessons on WhatsApp groups and then measured the changes in knowledge and patient care, as well as other factors like uptake, feasibility and accessibility,” she explains.

She found that WhatsApp-based microlearning for healthcare workers is “effective, feasible and well received” and 98 percent of those who participated said they would take part if training sessions were held weekly throughout the year.

While using WhatsApp for medical interactions is not new, Chisholm says a structured syllabus using microlearning for short, punchy sessions is a first.

“This type of learning is equally accessible to a rural clinic as to one in central Hillbrow. We can access people wherever they are. Nobody has to spend money getting anywhere and clinical services are not disrupted. And it doesn’t matter if they’re not in the live session: when they have a moment, they can go into their WhatsApp and read back on the lesson,” she says.

Working with the department of health on 6MMD

Chisholm has been working with the National Department of Health on their Six-Month Multi-Month Dispensing (6MMD) programme. The programme allows people living with HIV who are doing well on treatment and have suppressed viral loads to get a six-month supply of ARVs in one go. This makes life considerably easier for people, since they only need to go to the clinic twice a year; whilst also reducing workloads in the clinics. The programme started in August 2025 and is still being phased in across the country.

“In the pilot phase, the Department of Health did some really good online training and they used our WhatsApp training as an add-on to the longer form training,” says Chisholm.

“We started with one group and ran an eight-week course of 15-minute lessons once a week on WhatsApp. Sessions were case-based and included which patients are eligible for 6MMD, and which patients are not,” she explains. By the end of 2025, around 2 000 healthcare workers had been reached through these sessions.

Lynne Wilkinson, a technical expert with the International AIDS Society which supports the Department of Health on 6MMD, says the microlearning is “a great way to ensure we get to all the clinicians in the country and explain how the 6MMD programme works”.

She adds: “When a new policy comes out, it takes a long time for implementation to be scaled because ground level clinicians aren’t always aware of the changes or don’t have an opportunity to engage with how to implement the changes.”

Daniel Canham, a professional nurse and facility team lead for the NGO, TB HIV Care, at Idutywa Village Community Health Centre in the Eastern Cape, says they’ve found the microlearning sessions for 6MMD very useful. “It’s no secret that the waiting times in clinics are quite extensive, so we are trying to enrol all those qualified for 6MMD as quickly as possible to ease the burden on the clinic,” he says.

“The microlearning on 6MMD has been very helpful. Our staff don’t have to be out of the facility to attend it. They can run their normal activities and attend sessions of ten minutes maximum,” says Canham.

“Our professional nurses joined the WhatsApp microlearning sessions in September last year,” says Faith Maseko, a nurse lead based at Phola Park Clinic in Thokoza in Gauteng who works for the WITS Research Health Institute (RHI). The RHI supports the health department in the management of HIV and employs more than 30 nurses.

“When nurses are trained virtually, some of the information is forgotten, but when you’re on WhatsApp, you can go back and access the information that was shared. The scenarios provided are very useful. If you see a patient, with a similar scenario you can go back and see what was discussed and apply it to your own situation,” she says.

Department of Health backing

Foster Mohale, spokesperson for the National Department of Health, says the WhatsApp-based microlearning has been “an effective low-cost, high-reach supplement to formal 6MMD training”.

He adds: “Training gaps translate directly into service gaps, affecting quality, retention, and progress toward epidemic control. Microlearning addresses this risk by enabling continuous, bite-sized reinforcement of policy and implementation guidance, rather than relying solely on once-off training events. This approach supports frontline healthcare workers in applying 6MMD consistently under real-world service pressures.”

Mohale says evidence from the department’s broader capacitation strategy shows that lifelong, continuous learning, rather than episodic training, is essential for resilient health systems.

“WhatsApp microlearning aligns with this principle by supporting rapid dissemination of updates, peer learning, and sustained mentorship. When integrated with structured models and aligned to national guidelines, it can be effectively applied across HIV, TB, maternal and child health, non-communicable diseases, and health systems strengthening more broadly,” he says.

Republished from Spotlight under a Creative Commons licence.

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