Tag: Spotlight

Categories : Expert Opinion Respiratory DiseasesTags :

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

On By ModernMedia
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.

https://embed.bsky.app/embed/did:plc:jonfyv7sw4yyacspczyvtbrf/app.bsky.feed.post/3mfblooblek2s?id=30942957449070163&ref_url=https%253A%252F%252Fwww.spotlightnsp.co.za%252F2026%252F03%252F19%252Fto-eliminate-tb-we-need-to-make-testing-more-accessible-and-affordable%252F&colorMode=dark

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.

Read the original article.

Categories : Respiratory Diseases VaccinesTags :

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

On By ModernMedia
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.

Read the original article.

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.

Read the original article.

Categories : Healthcare Politics and RegulationsTags :

Spotlight’s Top 9 Health Stories to Watch in 2026

On By ModernMedia
With several important developments on the horizon, 2026 is set to be another eventful year in healthcare. Photo by Anna Shvets

19th January 2026 | By Marcus Low

From the limited rollout of a new HIV prevention jab to developments with new weight loss medicines, to high-stakes court cases relating to National Health Insurance (NHI), 2026 is set to be another tumultuous year in healthcare. Here are nine stories that Spotlight will keep a close eye on.

 1. How will things go with the local rollout of a new HIV prevention jab? 

Given the high rates of HIV in South Africa, the biggest HIV story this year is likely to be the rollout of a new HIV prevention jab at around 360 (roughly 10%) of South Africa’s public sector clinics. The jab, which contains the antiretroviral medicine lenacapavir, provides six months of protection against HIV infection at a time. It could be a gamechanger for people who, for whatever reason, struggle to take daily prevention pills. We will be tracking how and to whom the jab is made available and whether uptake meets expectations. 

As we reported last year, work is also underway on a new lenacapavir formulation that could provide 12 months of protection per shot. We’ll be scouring journals and conference programmes for new data on this formulation. 

2. Will we see better access to weight loss medicines? 

The class of diabetes and weight loss drugs called GLP1-RAs have taken the world by storm in recent years. Until recently, drugs like semaglutide (brand names Ozempic or Wegovy) and tirzepatide (brand names Zepbound or Mounjaro) were only available as injections. The GLP1-RA market is, however, set to be upended by the introduction of some of these medicines in pill form. The United States Food and Drug Administration (FDA) recently registered a semaglutide pill for use for weight loss. Another weight loss pill called orforglipron is also expected to be registered this year. One big question is when these pills will be registered and made available in South Africa and at what price. 

Another important GLP1-RA development this year will be the expiration of a key patent on semaglutide in India. This will open the door to generic manufacturers bringing their own versions of semaglutide to market – something that usually leads to substantial price reductions. We will be keeping a close eye on how this situation plays out and analysing what the implications are for people in South Africa. 

3. Might we see earlier than expected findings from pivotal TB vaccine trials? 

The one TB vaccine we have is over a hundred years old and only provides limited protection for kids. Several experimental vaccines are, however, currently being evaluated in late-stage clinical trials. Arguably, the most notable of these is the M72 vaccine, which is being assessed in a massive phase 3 study, partly conducted in South Africa. 

While timelines suggest most of the key TB vaccine studies will not yet have anything to report this year, it is possible that we might see a surprise or two. Findings are sometimes reported early if it becomes apparent ahead of schedule that a medicine or vaccine is clearly working, or clearly not working, as the case may be. Whether or not we see findings this year, it is important to start thinking about what a rollout might look like in our health system should results be as good as hoped. The M72 vaccine had around 50% efficacy in phase 2 trials, so there is reason for optimism. 

4. Will we see a concrete plan to address public sector healthcare worker shortages? 

Arguably, the most important dynamic in South Africa’s public healthcare system today is that provincial health departments are not employing enough healthcare workers across multiple categories. One reason for this is simply that budgets have generally shrunk over the last decade – obviously corruption and mismanagement in several provincial departments have made things even worse. There was a glimmer of hope in last year’s budget in which we saw a meaningful upturn in health funding for the first time in years, but that was at best a good first step toward recovery. As we enter 2026, our understanding is that all of the nine provinces are still facing severe healthcare worker shortages. 

More money for health in the next budget will certainly help, but there is a broader sense that government doesn’t really have a big picture vision for how to address the crisis. We do have a 2030 Human Resources for Health Strategy, but as with many such strategies, it seems to have so far gone largely unimplemented. 

5. Will enablers be held accountable for corruption such as that at Thembisa Hospital? 

One of last year’s big media moments was a Special Investigating Unit (SIU) press conference in which they described the extensive corruption said to have taken place at Thembisa Hospital. One snag, however, is that while the SIU can recoup funds and take matters to the Special Tribunal, the SIU does not conduct criminal prosecutions – though they can refer matters to the National Prosecuting Authority (NPA) for prosecution. Whether we will see successful NPA prosecutions relating to the Thembisa Hospital corruption is one of the year’s top questions. 

Unfortunately, even when the SIU does sterling work and delivers cases to the NPA on a plate, there is no guarantee that the NPA will do its job. One depressing example is that of Buthelezi EMS. Last year, the Special Tribunal ordered Buthelezi EMS (and other companies with similar names) to pay over half-a-billion Rand back to the state. The SIU also referred a related matter to the NPA in 2024 for prosecution, but Spotlight understands that the NPA has rather mind-bogglingly decided to drop the matter. 

6. Which, if any, senior health leaders will lose their jobs this year? 

While we won’t have national or provincial elections this year, that is no guarantee that we won’t see any health leaders losing their jobs. Over the last two decades, there have after all been many examples of people being ousted between elections, be it for purely political reasons or due to corruption scandals. 

Possibly the political leader in the health sector at greatest risk is KwaZulu-Natal MEC for Health, Nomagugu Simelane. Should the currently governing coalition of political parties in the province crumble, as it seems it might do, chances are several new MECs will be deployed, including for the health portfolio. 

There is also an outside chance that the country’s top health official, Dr Sandile Buthelezi, Director-General for Health in the National Department of Health, might be forced to step down. As reported by AmaBhungane, Buthelezi played a central role in an “irregular” R836-million oxygen procurement process and is also “at the centre of a Hawks investigation into allegations that he solicited a R500 000 bribe”. Our understanding is that Buthelezi has not been charged and that in the absence of charges he will stay in the job. 

7. What will happen in the landmark NHI court cases? 

Despite a new call for dialogue from Finance Minister Enoch Godongwana, chances for a political settlement over National Health Insurance (NHI) remains very low. The bottom line remains that Health Minister Dr Aaron Motsoaledi refuses to yield an inch on the version of NHI described in the Act and President Cyril Ramaphosa is not willing to force the matter. 

Instead, it seems the battle over NHI will this year be fought mainly in the courts. At our count, there are at least eight cases challenging the NHI Act, parts of the Act, or the process resulting in the Act. A first development to look out for is whether or not some of the cases will be combined and heard together. In case you missed it, last year we published a two-part series in which we tried to pin down the issues on which these court cases are likely to turn (see part 1 and part 2). 

While we will cover the NHI court cases in some depth, we will also try to foster constructive discussions on health reforms on our opinion pages and in our analysis. In our view, it is dangerously limiting to reduce the debate over South Africa’s healthcare reforms to a simple binary of whether one is for or against NHI. 

8. What will be left of the FDA, NIH, and CDC by the end of 2026? 

It used to be the case that United States Food and Drug Administration (FDA) decisions and health advice from the United States Centres for Disease Control and Prevention (CDC) carried a lot of weight around the world. In recent months, however, there have been increasing signs of political interference at these institutions and a turn away from evidence-based policy making. It seems inevitable that we will see more of the same in 2026 and the credibility of both the CDC and probably also the FDA will be further diminished. 

Similarly, the US National Institutes for Health (NIH) has been the world’s leading funder of health research for many years. But as with the CDC, the work of the NIH has been overly politicised over the last year and its reputation for rigour and scientific excellence has already been severely degraded. As with the FDA and CDC, the outlook is bleak. 

9. How well will SA and other countries recover from last year’s US aid cuts? 

With the dust settling after last year’s severe and abrupt cuts to US healthcare aid and US funding for medical research, the longer-term impacts of those cuts in South Africa and neighbouring countries should become clearer this year. Among others, we will get the first reliable estimates of key HIV and TB indicators for 2025 (reliable figures for a specific year are typically only published in the subsequent year). New HIV estimates from the Thembisa mathematical model (Spotlight’s preferred source for HIV estimates) should be out around the middle of the year, while new World Health Organization (WHO) TB estimates are usually released in November. 

Last year Motsoaledi was widely criticised by activists for underplaying the seriousness of the cuts for South Africa’s HIV response and the scale of specialised services and capacity that was destroyed here. Eventually some extra funds were made available in response to the cuts, but it amounted to only a small fraction of what was lost. The harsh reality is that in some places the aftermath of the aid cuts will be felt for years to come. 

At an international level, we are also not convinced that a clear roadmap has been set out for building back better after US withdrawal, though we’d be happy to be proven wrong. What is clear though is that entities like the WHO and UNAIDS are facing unprecedented financial and political pressures – it seems possible that UNAIDS will no longer exist a year from now. Much reform has already been undertaken at the WHO. By the end of the year, we should have some sense of whether things have stabilised and whether a coalition of willing nations is truly committed to keeping the WHO and multilateralism in health alive. 

We have outlined only nine health issues in the above, but there are of course many more questions that we could have added to this list. Some of those include: 

  • Whether we will see meaningful improvement in the South African government’s response to non-communicable diseases such as diabetes, cancers, and mental health conditions. 
  • How well implementation of South Africa’s latest TB recovery plan is going, and in particular how we are doing against the target of testing five million people in 12 months. 
  • How climate change will impact people’s health and whether the South African government is prepared for it. 
  • Whether South Africa will see real progress in addressing antimicrobial resistance. After adopting a good policy a few years ago, it appears momentum has been lost. 
  • Whether the state will start taking xenophobia in the healthcare system and around clinics and hospitals more seriously, as a recent court judgment requires it to do. 
  • Whether a serious effort will be made to better regulate private healthcare and to bring down the cost of private healthcare services and medical scheme membership – that after a half-baked effort to create a new tariff-determination framework was launched and then canned last year. 
  • Whether we will see legislation introduced amending the Patents Act in line with a policy adopted by government in 2018 and whether we’ll see progress on the much-delayed State Liability Bill, which should have relevance for the state’s vulnerability to medico-legal claims. 
  • Whether we will see concrete steps forward with the new electronic health records and data systems government is developing. 
  • What progress we might see with the local production of vaccines and pharmaceuticals – one of the areas in which we are quite optimistic, despite the lack of coherent and enabling government policy. 
  • What impact AI will, or will not, have in our healthcare system this year. 

Are there issues not mentioned here that you think Spotlight should cover in 2026? Let us know by commenting below this article or by tagging us on BlueSky. 

*Low is the editor of Spotlight. 

Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : Expert Opinion Respiratory DiseasesTags :

Janet Giddy | If COVID-19, Why not TB? Mr President, it’s Time for a Family Chat

On By ModernMedia
President Cyril Ramaphosa addresses the nation in 2021 on developments in the country’s response to the COVID-19 pandemic. (Photo: GCIS)

By Janet Giddy

South Africa had several “family chats” in which President Cyril Ramaphosa addressed the nation during the height of the COVID-19 pandemic. He should do the same for tuberculosis, argues Dr Janet Giddy of the advocacy group TB Proof.

Recently, I was flying home and got chatting to the stylishly dressed woman in the window seat next to me. We asked each other the sort of questions that traveller’s often do. Suzie (name changed) was going to Cape Town to facilitate an artist’s workshop. I told her that I worked for an NGO that did tuberculosis (TB) research and advocacy. Suzie nodded pensively, then said: “My dad had TB”. I was just thinking how to respond, when she added: “he died from it”.

I have conversations about TB almost every day, and have previously written about high-altitude chats with fellow travellers. I get into these conversations not because TB work is my “day job” – which it is – but because I am a TB activist, and a survivor of childhood TB.

There are many remarkable things about TB that keep me engaged, enraged and activated. For example, that 29 934 people were diagnosed with TB in 2024 in the Cape Town metro, which was more than the combined number diagnosed with TB in the whole of the United States (10 347), the United Kingdom (5 480), France (4 217), and Canada (1 258). The population of these four countries combined is over 500 million, while Cape Town has a population of just under five million people. If you do the math, the risk of getting TB clearly depends massively on where you live. If these figures do not shock you, they should.

Why are so many people in South Africa unaware and seemingly unconcerned about the extraordinarily high numbers of people infected with TB in our country? Could we take TB more seriously as a country? My answer is yes.

If COVID-19, why not TB?

As expected, South Africa worked up a huge head of steam at every level of society about COVID-19. I think back on President Cyril Ramaphosa’s regular avuncular “family chats” to the nation. In the first COVID-19 “family chat”, our president told us:

“This is a decisive measure to save lives of South Africans from infection and save the lives of hundreds of thousands of our people. While this measure will have a considerable impact on people’s livelihoods, and on the life of our society and on our economy, the human cost of delaying this action would be far, far greater.”

Why has Ramaphosa not ever spoken in this intimate “family style” way to the nation about how important or urgent it is to tackle TB? A disease which continues to cause significantly more suffering and death than COVID-19 did.

In 2018, our president spoke to the international world about TB, when he addressed the President of the General Assembly of the United Nations (UN) and Director-General of the World Health Organization at the first ever UN High-Level Meeting on Tuberculosis. With great gravitas and in oratorial style, Ramaphosa said: “This … is a historic opportunity that we must embrace if we are to effectively respond to a disease that has killed more people than smallpox, malaria, the plague, influenza, HIV and AIDS, and Ebola combined. This meeting is taking place in the year of the centenary of the birth of South Africa’s founding President, Nelson Mandela. President Mandela was a survivor of tuberculosis, which he contracted while in prison, and was firmly committed to the campaign against the disease.”

Ramaphosa went on to highlight the social determinants of TB, including poverty, unemployment, poor nutrition, overcrowding and social stigma that fuel the spread of diseases. He also noted: “In South Africa, TB is the biggest cause of mortality in the general population, especially among men.”

This was an excellent message, but since 2018, our president has not had much to say about TB in public or to South Africans. It would be powerful and impactful if he were to talk about TB as a national emergency that requires a coordinated “family response” as a nation.

In considering the seriousness of TB as compared to COVID-19, let’s look at mortality.

By November 2022, the official number of deaths recorded as being due to COVID-19 in South Africa was around 102 000, approximately 34 000 per year when averaged out. Official numbers are however widely considered to be an underestimate. The Medical Research Council estimated in the region of 300 000 excess deaths relating to COVID-19 from 2020 to 2022, with around 85 000 in 2020, 200 000 in 2021, and around 15 000 a few months into 2022. Not all of these excess deaths would have been directly due to COVID-19, but it is likely that over 80% was (say 240 000 over the three years).

By comparison, TB has in recent years been claiming between 50 000 and 70 000 lives per year, based on estimates from the World Health Organization (WHO) and the Thembisa mathematical model. Thus, while there were many more COVID-19 deaths in 2021 than there were TB deaths, TB deaths almost certainly surpassed COVID-19 deaths in 2022 and subsequent years. The more one zooms out, the more the steady torrent of TB deaths over the last five, 10, 20 years, dwarfs the spike in COVID-19 deaths around 2021.

‘We are all at risk’

Back to my recent high-altitude chat in the plane: somehow, it was a uniquely South African sort of conversation. What is the chance that, while cruising at 10 000 meters over the Atlantic on a flight between the United States and France, that you’d sit next to someone whose parent recently died of TB? An extremely small chance. So, I would contend that all South Africans do need to know about TB, which is a disease that affects families profoundly.

It’s time for South Africa to have family chats about TB. There are many reasons to have these chats, starting with the fact that we are all at risk of getting it, given that we live in a country with a high TB prevalence – it was estimated that 389 people per 100 000 in South Africa fell ill with TB in 2024. We could compare this with the 2024 figures for the United Kingdom, at 9.7 per 100 000, which is higher than the United States’ rate of 3.2 per 100 000. For those who are interested, you can look up the latest numbers for different countries on the WHO’s excellent TB data portal.

The bottom line is that the higher the TB prevalence in the country you live in, the more chance that you or a family member could get TB. This is because it is caused by a bacteria which is transmitted through the air via talking, singing and coughing, so anyone can breathe it in – as was the situation (and therefore, panic) with Covid.  The mode of transmission is the main similarity between TB and COVID-19 – there are lots of differences.

While some people are more at risk of getting TB, anyone can get TB, from any background. As a recent example: in 2024 Anna (name changed), a professional woman who lived in a green leafy suburb, was referred to me by her GP. Anna was shocked and outraged that she had been diagnosed with TB: “Janet, I feel as if I have been infected with a third world plague”. Anna wanted to believe that she had been infected with TB on a visit to India 18 months previously, but together we traced back her potential exposure and worked out she most likely was infected six months earlier, by a family member in a care home. Because Anna and her GP did not think about TB, it took more than a month of her coughing, losing weight and having no energy and taking several courses of antibiotics, before the diagnosis was finally made. By this time, she was very unwell, and her family members and many clients were at risk of getting TB.

Anna’s experience highlights how stigmatised TB still is as a disease. Stigma is a challenge to people from all backgrounds, and there are different reasons for it. Talking about TB more openly is one way to reduce stigma.

As with many other diseases, the earlier TB is diagnosed, the better the chance of full recovery, with no residual lung damage. There is effective medication to treat TB, and although treatment typically takes 6 months, it is not lifelong unlike chronic diseases like diabetes, hypertension and HIV. Young children with uncomplicated lung TB take medication for 4 months only.

Recent TB guidelines recommend that all close contacts of people diagnosed with TB (usually family or household members) should be tested for TB (even if they don’t have symptoms), and if they test negative, they can be offered TB preventive treatment (TPT), which will protect them against getting active TB disease. There is also more “user friendly” TPT now available, which consists of taking medication once a week for 3 months – a total of 12 doses only. Counselling people with TB needs to be family focused, given these new developments.

So, my challenge to readers is to have regular intentional conversations about TB with family and friends, with colleagues, in airplanes, and while waiting in queues.

Keely, a young women who read a previous Spotlight article I wrote, said she was amazed to discover that her colleague was very anxious because her mother was being treated for TB. If Keely had not decided to talk about TB at work, she would not have been able to offer her colleague support.

Try having a conversation about TB in the next week and see what comes of it.

*Giddy is a consultant at the TB advocacy group TB Proof.

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 :

EDITORIAL | What has Actually Happened on NHI This Year?

On By ModernMedia

By Spotlight

It is not a stretch to say that the NHI Act has been one of the most controversial pieces of legislation in post-apartheid South Africa.

Since President Cyril Ramaphosa signed it into law in May 2024, just two weeks ahead of the national and provincial elections, at least nine different court cases have been launched against the Act, or specific provisions in the Act. None of those cases have made it through the courts and it seems likely some might be combined. 

In one preliminary to the bigger court battles, the North Gauteng High Court in Pretoria ordered Ramaphosa to provide the record of his decision to sign the act, but the President is challenging that order. 

A subtext to the torrent of court cases is the sense that it is only through litigation that the NHI Act might be scrapped, or that some of the most controversial provisions in it might be repealed. The alternative to litigation, political compromise, for now seems dead in the water. There was some hope for such compromise around a year ago when Business Unity South Africa and several healthcare worker groups pushed government for a change in course – but while the Presidency seemed open to considering changes, the health minister did not, and eventually the ANC, and government with it, decided to buckle down behind their current NHI plans. 

The door to political compromise could of course reopen should the balance of political power in the country change – as it will surely do after the 2029 elections, if not earlier. 

To the courts then 

There has been much media coverage of the various court cases challenging the NHI Act. Understandably, a lot of the public statements were aimed at drumming up public support for the various points of view. In the end, the courts will hopefully look past the rhetoric and politicking and judge the cases on their merits. 

This is why in recent months Spotlight put substantial resources into combing through seemingly endless court papers and chatting to a variety of lawyers in an attempt to sift the wheat from the chaff. As with many other court cases we’ve reported on, we suspect the various NHI-related cases will in the end turn on just a few key legal questions. In a special two-part series, we tried to pin down what these key legal questions are likely to be – you can see part 1 here and part 2 here. (Thank you to the three lawyers we quote in the article, as well as those who shared their views, but opted not to be named and quoted.) 

In our view, this crystallisation of the legal case against the NHI Act, and/or specific provisions in the Act, is the most notable NHI-related development this year. After all, a major ruling against the Act could make much else moot. 

Other NHI developments 

Meanwhile, the Department of Health is moving ahead on the assumption that NHI will be implemented as envisaged in the Act. The first formal step towards setting out the proposed governance structure and processes of the NHI Fund is underway with draft regulations that were published in the Government Gazette in March. Amongst others, the regulations provide for the appointment of the board of the NHI Fund, the fund’s chief executive officer, and for a benefits advisory committee and a healthcare benefits pricing committee. In the background here is the fact that, until the NHI Fund has been established as a public entity, it cannot be awarded a budget by parliament. 

One source of funding for NHI could be the phasing out of medical scheme tax credits. This is according to a presentation by the National Health Department’s NHI lead, Dr Nicholas Crisp, who was addressing the Standing Committee on Appropriations in the National Assembly. The presentation notes that medical scheme tax credits could raise as much as R34bn for the NHI Fund by 2027/28. At the moment, eligible beneficiaries receive medical scheme tax credits to the value of R364 per month for the primary member, R364 for the first dependant, and R246 for each additional dependant. The rough idea is that tax credits would first be phased out for high-income earners. This would eventually be followed by the state scrapping medical scheme subsidies to civil servants. 

But Finance Minister Enoch Godongwana seems unconvinced. He told BusinessDay: “It’s actually an attack on the middle class”. 

And indeed, the proposed scrapping of medical aid subsidies has added fuel to suggestions that government is intentionally undermining the viability of private healthcare in South Africa. A set of recommendations on how to better regulate the country’s private healthcare sector remains largely unimplemented six years after being published. Government did publish draft regulations for tariff determination in the private sector in February, but, as we recently reported, those draft regulations have now been withdrawn. In fact, those draft regulations were so poorly thought out that one wonders whether they were a serious attempt at addressing the issue in the first place. 

According to Crisp’s presentation, NHI could take “10, 15 or more” years to implement. There is some welcome realism in this. Rather absurdly, Section 57 of the NHI Act still states that it will be introduced in two phases, between 2023 and 2026, and between 2026 and 2028. 

Several experts have suggested to Spotlight that, mainly for financial reasons, NHI is essentially dead in the water and that the more serious people in the government and the ANC know this. Few are however willing to say this publicly. Others, like Crisp and Health Minister Dr Aaron Motsoaledi, would of course beg to differ, and mean it. 

Not the only solution 

One thing that should not get lost in all this is that things really do need to change. Apart from being extremely unequal, much of the healthcare system in South Africa is deeply dysfunctional. But Motsoaledi is wrong when he suggests that the specific system set out in the NHI Act is the only possible solution. As we’ve previously argued, there are other viable paths to universal health coverage, even if the current set of leaders in the ANC refuses to seriously consider them. 

One of the great tragedies of NHI is that for all the noise, we have never really had an informed public debate about the policy options and the reasons for going with one set of health reforms rather than another. There were few things as depressing as watching members of parliament’s portfolio committee for health reducing someone’s nuanced and constructive feedback on the Bill to a simple question of whether someone is for or against NHI. The ANC of course had a majority in parliament prior to the 2024 elections, so maybe there was a sense that they did not need to listen and do the hard work of engaging and bringing people along with them. 

Either way, it now seems likely that in 2026, the courts will have to make one or more landmark rulings that will determine the future of NHI. We have some idea of what the key issues will be on which those cases will turn, but as to how the courts will decide, your guess is as good as ours. 

Republished from Spotlight under a Creative Commons licence.

Read the original article.