Tag: Spotlight

Categories : HospitalsTags :

How Far Will 800 New Posts Take Western Cape Health?

On By ModernMedia
More than 33 000 healthcare workers helped patients more than 20 million times in the Western Cape in the last financial year. (Photo: QuickNews)
21st April 2026

By Christina Pitt

The Western Cape health department is ramping up its workforce with 800 new frontline posts. After years of austerity and with long lists of vacancies, questions now turn to how soon the new posts will translate into staff on the ground.

The Western Cape health department is adding more than 800 staff to frontline and support services in a bid to strengthen a health system in which hiring has been stifled by years of austerity.

Health MEC Mireille Wenger announced a recruitment drive, which includes 316 nurses, 124 doctors and 80 emergency medical personnel. For medical workers to have more time at their patients’ bedsides, she said this plan also targets 38 allied health professionals, such as physiotherapists and dieticians, alongside 278 administrative and management staff.

As it stands, more than 33 000 staff in the province helped patients more than 20 million times in the last year, according to Wenger. For public hospitals and clinics, the news of the new jobs offers some hope that the constant pressure on staff capacity will be relieved.

One example of where the new jobs may make a difference is with surgical backlogs in the province. Of the nearly 100 000 people waiting for surgery in 2025, 87 975 have been waiting for more than a year, while 20 027 have been on the list for more than 60 months. Some of these people entered the system during the height of the Covid-19 pandemic and have been left in limbo through years of budget cycles and hiring freezes.

The budget paradox

While governance has been poor in most of South Africa’s nine provincial health departments, with corruption and looting in Gauteng being a particular concern, the Western Cape health department has received seven consecutive clean audits, maintained stable leadership and largely avoided controversy.

As part of a total R106.8 billion package over three years, the Western Cape health department’s 2026/27 budget is R34.47 billion, which is a 6.25% increase from last year.

When adjusted for inflation, provincial health budgets have been falling for most of the last decade. This has contributed to constrained hiring budgets and exacerbated staff shortages. The tide finally turned with above-inflation increases in the 2025 and 2026 budgets – although belts remain very tight.

Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, said that the Western Cape’s health department is a relatively well-run machine yet is dogged by underfunding.

Understanding this requires a look at how provincial health departments are funded.

While provincial health departments get some funds via sources such as provincial revenue and conditional grants, most of their funding flows from the province’s slice of the national budget. For the 2026/27 financial year, the country’s nine provinces was allocated R810.5 billion.

How much each province gets is determined by the provincial equitable share formula, which has been under review since 2015. The provincial equitable share formula considers factors, such as the size of the school-aged population and the number of people living in poverty. Its health component considers factors like the population without medical aid, adjusted for health risk, medical aid membership, and clinic and hospital visits.

Provinces decide how they divide their share of the budget between their provincial departments.

There are however some issues with the provincial equitable share formula. Firstly, it makes use of certain data from the South African census, which means that the information does not reflect current demographic and service realities, said Van den Heever (the census is conducted only every 10 years). Secondly, the usefulness of the results from the latest census of 2022 is in question because certain data sets, such as income, mortality, fertility, and employment figures, were missing.

As a result, National Treasury has been unable to fully update its calculations to factor in the census 2022 data, contributing to a lag in how population changes are reflected in budget formulas. As far as we can tell, National Treasury has relied on datasets updated at different times in the year, such as Stats SA’s mid-year population estimates, allowing it to phase in changes gradually rather than introduce sudden adjustments.

Broadly, Van den Heever said the result is a system forced to pick up the tab for a population the national budget hasn’t yet acknowledged. Citing an example linked to health, he says the formula ignores patients who travel from other provinces to access specialist care at tertiary hubs like Groote Schuur Hospital in Cape Town.

The claw-back

Some of the vacancies in the Western Cape health department reflect periods when the government cut funding due to broader economic challenges, Doctor Saadiq Kariem, the department’s Chief Operating Officer, told Spotlight.

Indeed, between 2021 and 2024, the province absorbed an R8.4 billion reduction in its budget allocation.

This has forced leadership to make some tough calls, including vacancies for frontline services like health. Kariem explained: “It was a process of consciously delaying the filling of those posts so that we could make up for the loss in funding. Sometimes we, along with local managers, decided to shift posts from a vacancy to another part of the service platform based on service needs and pressures.”

“You know, these are heart wrenching choices because all of those posts are absolutely essential and I know that not filling them will have an impact on the service provision and result in poorer health outcomes. So yes, the austerity measures had a significant impact on the post filling rate,” he added.

According to the health department’s annual report, 3 737 people left the department’s employment in the 2024/2025 financial year. By the end of March 2025, 2 772 funded posts remained vacant.

Nationally, vacancies among nursing staff are particularly acute. As of 2023, across enrolled, auxiliary, community service, professional, primary healthcare and specialist nurses, there were about 14 000 vacant posts across the country.

Sabelo Ntshanga, Western Cape provincial secretary of the Democratic Nursing Organisation of South Africa, said burnout caused by workload is the main driver of attrition.

“The reality is that it’s not being filled quickly. It takes up to a year sometimes while the demand in the communities remains high,” he said. “Burnout is underreported and when the nurses get sick from burnout, that’s another burden on top of the shortage of staff.”

Overall, while the 800 new posts represent a step in the right direction, it appears to be more about holding the line than an actual growth spurt. As Kariem says, it represents an effort to “claw back” towards a stable staffing baseline while attempting to invest in future service capacity.

The red tape

Things won’t change overnight though. Wenger noted in her speech that “it will take time to fill these posts”.

Kariem explained that recruitment follows a multi-stage process as vacancies are advertised, followed by shortlisting and interviews. Final appointments then require approval at different levels of the system, depending on the seniority and specialty of the role. “We see delays throughout the process,” he said. “Once there is the ability to advertise a post, we have to give sufficient time for an advert to run… then for interviews and for permissions to follow.”

This means that even funded posts can remain unfilled for extended periods as they move through administrative and approval processes.

Adding further delays to an already complex process, the National Treasury and the Department of Public Service and Administration (DPSA) advised cost-containment measures in October 2023, which was extended until March 2025. It required additional approvals before recruitment could proceed.

Wenger bemoaned these regulations when it was rolled out. “The DPSA’s recent regulations, intended to slow down recruitment, are doing real harm to large service delivery departments like Health. Staff retire or move on, and yet our system lacks the agility to replace them fast enough. This leaves remaining healthcare workers overburdened, and services strained,” she said.

At the same time, not all vacancies can be filled due to shortages of suitably qualified candidates, particularly specialist nurses. Kariem explained that this in part reflects longer-term gaps in investment in postgraduate training. He said the department is using recent budget increases to strengthen human resources information systems to better identify skills gaps and fill vacancies.

These staffing pressures also affect training and retention. Ntshanga said they limit the system’s ability to release nurses for professional development, constraining career progression and contributing to low morale.

At Groote Schuur Hospital, the department noted that nursing staff shortages have affected multiple units across the hospital in 2024/25, contributing to reduced service capacity.

For Ntshanga, the new posts are a small drop in a very large bucket. “As much as it is a good deed from the department, it doesn’t come close to what we need on the shop floor,” he said.

Republished from Spotlight under a Creative Commons licence.

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Categories : Medical Research & TechnologyTags :

EDITORIAL | After Major Research Cuts, SA Charts a New Path

On By ModernMedia
To limit the damage from the US research cuts, the SAMRC mobilised a rescue fund of about R600 million.

Spotlight Editors

It has been a bruising year or so for medical researchers in South Africa with the US pausing, cancelling, and then resuming some grants. But as bad as things were, what played out wasn’t the worst case scenario, and momentum is now building toward recovery.

For decades, the United States government has been the world’s top funder of medical research. When it started cutting research funding last year, South Africa was caught in the firing line. This is because the US administration decided to specifically target South Africa, but also because South Africa was uniquely exposed due to the sheer volume of US-funded research here.

Over recent decades, South Africa built an impressive network of research groups and infrastructure to support high quality research – all underpinned by a strong regulatory environment, several good universities, and many productive partnerships with research groups from across the world. All this, plus the fact that we have large TB and HIV epidemics, means that South Africa was, and still is, one of the best places in the world to conduct research on these two diseases.

But a weakness of South Africa’s impressive research infrastructure was its overreliance on US funding.

To be clear, this was not an overreliance on aid or charity. South African researchers won grants from the US by coming out on top in rigorous and highly competitive selection processes. Much of the research done here benefited people around the world, including in the US.

Instead, the thing that we overly relied upon was that the US would continue to make medical research grants in a way that is rational and in our common interest.

There was much chaos and uncertainty last year with the pausing, cancellation, and resuming of grants. One small positive is that bad as things were, what played out wasn’t the worst case scenario we seemed to be heading for. At least some projects got their funding flows restored. You can read more about that in this Spotlight article.

But there is no doubt that the situation remains very bleak. While some studies that were already underway will be completed, it seems very unlikely that the US will fund any new studies in South Africa in the coming years. Given the historic scale of US investment here, the total volume of clinical trials conducted in South Africa will almost certainly fall precipitously.

Charting a new course

One ray of light in all this has been the response from the South African Medical Research Council (SAMRC) – probably the best run of all the entities linked to the Department of Health.

To limit the damage from the US research cuts, the SAMRC mobilised a rescue fund of about R600 million. This includes major contributions from National Treasury, the Gates Foundation, the Wellcome Trust and the ELMA Foundation.

Some of this funding has already helped sustain dozens of research projects and protect vital expertise during a period of instability. The current funding supports work in HIV, TB, newborn and child health, as well as non-communicable and other infectious diseases.

One example is a cutting-edge HIV vaccine clinical trial that began in January at the Desmond Tutu Health Foundation’s clinical research site at Groote Schuur Hospital in Cape Town. While still in its early stages, the study aims to help piece together what an effective HIV vaccine might look like.

Beyond the SAMRC’s efforts, universities and research institutions have also stepped in, raising funds to safeguard projects and retain skilled staff whose jobs were at risk.

Even so, we are still facing a massive net loss to money for medical research in South Africa.

What to do?

Funding from international partners will remain vital in South Africa. For now, the US government still invests substantial funds in South Africa, as does several philanthropies and the European Union, through the European & Developing Countries Clinical Trials Partnership. There are also new partnerships such as one we recently reported on between South African and Korean researchers.

Such partnerships are not just about money – science thrives where there is collaboration across national borders. In fact, almost all of the most important TB and HIV clinical trials conducted in South Africa in the last two decades were collaborations between researchers from multiple countries. No matter how you slice it, collaboration with international partners will remain an essential foundation of the medical research landscape in South Africa.

The problem was never that South African researchers took too much money from the US or other donors, or worked too closely with researchers based in other countries. One might quibble on details here and there, but on the whole, US-South African research collaboration in recent decades has been a resounding success.

Rather, the problem was that we invested so little of our own funds that we became overly vulnerable to changes in external funding.

Professor Ntobeko Ntusi, president and CEO of the SAMRC, previously told Spotlight that the SAMRC receives in the region of R2 billion from government per year, including funds from both the Department of Health and the Department of Science and Innovation.

Unlike so many parts of our government, the SAMRC is a well-run entity that got clean audits in each of the last five years. This strongly suggests that money allocated to it won’t be wasted or looted. If we understand recent messaging from the Finance Minister and National Treasury, this is precisely the kind of clean government spending that should be rewarded in future budgets.

Relative to health budgets more generally and to what government has historically spent on entities such as South African Airways, the SAMRC’s budget is tiny. As far as we can tell, the current funding level is largely a product of history – apart from the still widespread atmosphere of austerity, there really isn’t any other reason why the budget shouldn’t be scaled up over the next three years to be double what it is now.

The SAMRC supports a sector in which South Africa has truly world-class capacity – capacity that as we speak remains under threat. More than just the research studies and the jobs for young scientists, what is at stake here is the idea of South Africa as a place where we can do world-class medical research. Allowing funding cuts to extinguish this bright spark, would feel like a victory for Afro-pessimism.

The reality is that if President Cyril Ramaphosa and National Treasury seizes the opportunity, the shock of the US funding cuts could be turned into a bright new beginning for medical research in South Africa – all at a price that in relative terms is very low. Let’s hope they have the vision and ambition to seize the day.

Disclosure: The Gates Foundation is mentioned in this article. Spotlight receives funding from the Gates Foundation, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags :

Moonlighting, Money and Morals in a Looted Health System

On By ModernMedia
Some healthcare workers in the public sector are allowed to moonlight in the private sector to earn extra money, subject to certain conditions. Photo by CDC on Unsplash

By Joan van Dyk

The Department of Health allows some public sector doctors and nurses to moonlight in the private sector, but the relevant policy and its implementation caused much controversy over the years. Set against the wider management dysfunction in several provincial health departments, the issue is now coming to a head.

Professional nurse Nomsa Dlamini* has been picking up extra shifts in Gauteng’s private health sector for years, without the required approval from her public sector managers.

The health department has no record of this work, a breach of the rules meant to regulate “moonlighting” among state employees.

She says the benefits of keeping her extra shifts off-book far outweigh the risks of getting caught. If that ever happens, she’s happy to face the consequences, such as disciplinary action. For her, that’s still preferable compared to the cost of following the rules.

Over the course of her 20-year career, Dlamini says she has watched retaliation against her complying colleagues, often in the form of a punishing shift schedule that makes rest unlikely and private sector shifts impossible.

Losing the extra income would be the worst-case scenario, she says.

Dlamini is not the only one bending the rules to avoid backlash.

Moonlighting often not declared

A survey of 1 397 health workers in Gauteng and Mpumalanga found that among public sector employees who were moonlighting, just 20% of professional nurses said they had permission, compared with 85% of doctors and 13% of rehabilitation therapists. The results were published in the South African Medical Journal in 2025.

The fear that managers would refuse permission, or that the act of asking would be met with hostility were high on nurses’ list of reasons for side-stepping the system.

The policy that allows moonlighting – usually called Remunerative Work Outside of the Public Service (RWOPS) – started in the 1990s as a retention strategy with few official rules. The government has gradually layered oversight roles and overtime limits into the system to stem abuse, with mixed success.

The latest policy guideline includes compulsory quarterly reporting to the Department of Public Service and Administration and tighter consequence management. Circulars and job adverts suggest the government is in the process of further beefing up its moonlighting monitoring systems but for now there is little detail about their plans on the public record.

A broader overhaul of South Africa’s health system staffing strategy is on its way too. A ministerial advisory committee (MAC), set up by Health Minister Dr Aaron Motsoaledi in April 2025, hosted an indaba in November 2025 and has sent out questionnaires to gauge health workers’ expectations and concerns about issues including moonlighting, overtime, and community service.

But for some nurses, the details of how their work is regulated has become less important than the everyday task of making a living. Dlamini says she and her colleagues understand why the government needs to make these rules, but they feel the health system no longer has the legitimacy to enforce them. They suggest that years of corruption has gutted the system by draining resources, stripping services, and eroding trust.

Over at Tembisa Hospital, for instance, the Special Investigating Unit (SIU) found that medical supply spending dropped by nearly three-quarters in the year after massive graft was uncovered there. This suggests that money was being spent on ghost stock and overpriced consumables, not the supplies nurses need to do their work. Health workers and patients often flagged medicine shortages at the hospital and were reportedly still borrowing food and drugs from other facilities late in 2025.

Dlamini herself says she has had to push her aching body through understaffed shifts with stretched resources for years, and now she’s being asked to help restore what others have taken.

Worst of all, she says, is an ethics course the higher ups want staff to complete. The request feels alien and disconnected from the realities of a department that has allowed syndicate-linked health workers to siphon millions away from patients. A professional nurse at Tembisa allegedly pocketed nearly R28 million by approving appointments and managing the illicit flow of one of the three syndicates described by the SIU. According to the SIU, a nurse assistant made at least R7.3 million, the equivalent of well over two decades of legitimate salary.

So until Dlamini hears that her pay will be withheld if she doesn’t do the ethics course, she simply refuses. “It’s a slap in the face,” she says.

Standoffs and moonlight mistakes

In 2023, City Press reported that more than 8 700 Gauteng health employees meant to file disclosures had failed to report their financial interests. Nearly two-thirds of the province’s health staff were facing suspension.

The health department’s risk office sent an email saying the rule breakers should “make themselves available at the MEC’s boardroom … to explain themselves”. City Press reported that at least one hospital told its staff not to go.

Whether it is such standoffs between governmental leadership and public servants or the state’s inability to effectively regulate moonlighting, it is patients who ultimately pay the price.

Sometimes, patients aren’t being monitored because their nurse is selling cosmetics for a multi-level marketing scheme in the tea room, Dlamini says. Or a nurse has called in sick when they’re really working in the private sector while still being paid by the government.

There’s also a gruelling cycle that begins after a nurse spends their day at a private facility and then reports for night duty at a public hospital. At some point in the night, they might disappear to get some sleep, leaving an even smaller team to make sure dozens of patients are clean, comfortable and medicated by morning.

Jacky James and Isaac Rabotapi, both Gauteng shop stewards for the Democratic Nursing Organisation of South Africa (Denosa) say they know of many night shift tragedies. The pair regularly represent nurses during disciplinary hearings.

In one instance, they say a six-month-old baby needed a drip. The ward was short staffed and the nurses in attendance were exhausted. Nobody was monitoring the infant once the drip was in. By the time somebody checked up several hours later, the infusion had leaked into the surrounding tissue, causing irreversible damage. Surgeons had to amputate the infant’s entire hand.

The two shop stewards say this is one of many instances they believe are linked to exhaustion and compromised judgement of nurses who work non-stop.

In one nationally representative study from 2015 just over half of surveyed nurses said that they are too tired to work while they’re on duty. This study found no statistically significant link between moonlighting and medico-legal claims but South Africa’s action plan for health sector staffing acknowledges that burnout and clinical mistakes probably contribute to the health department’s sky high malpractice bill.

In a submission to Motsoaledi’s advisory committee, the South African Medical Association (SAMA) describes a health system trapped in a destructive loop in which low base salaries and chronic understaffing feed off each other. Clinicians rely on excessive overtime and side jobs as a financial lifeline. While this keeps services running 24/7, they say extreme burnout and fatigue triggers medical errors and drives overextended staff to quit. When people leave, SAMA says, the staffing gap widens, forcing those who remain to work even more hours. This restarts a cycle that ultimately relies on overworking clinicians to prevent the system from collapsing, SAMA maintains.

The high cost of low salaries

Dlamini, James and Rabotapi are all professional nurses. Among them, they have about 85 years of experience in South Africa’s public hospitals.

“I love my job,” Dlamini says. “For me, it’s about the patients. But the workplace has become unbearable.”

It is worth pointing out here that, even while much of what we describe in this article is negative about the state of nursing in South Africa, we have in the course of our reporting over the years come across scores of nurses who are deeply committed to serving their patients. We have profiled some of these nurses – see here, here, here, and here.

James and Rabotapi say they also used to love nursing, but they both switched to union work in an effort to help patients by improving the system in which they’re treated.

Rabotapi’s view of the system is even worse now that he’s on the road for Denosa because he can see the full extent of poor nursing care. “The lack of empathy is shocking.  I’ve seen nurses addressing their patients by conditions instead of their names. That’s a violation of their right to privacy and confidentiality.”

Harsh treatment seems to have become a rite of passage, passed on from older nurses to young recruits, says James. This is especially visible in maternity wards where nurses can be judgemental or cruel towards young mothers, she says.

Obstetric violence, which includes verbal or physical abuse, humiliation or forced medical procedures is widespread. A 2025 report estimates that 1.79 million people who gave birth in KwaZulu-Natal and Gauteng experienced some form of obstetric violence in the past decade.

In February, a coalition of local human rights organisations including Embrace and the Centre for Applied Legal Studies sent Motsoaledi a memorandum demanding change.

By August, they want legal recognition of this abuse and for respectful maternity care to be added to district performance dashboards. They also demand an explicit ban on hiring freezes in sexual and reproductive health services to ensure good staff levels and an adequately funded budget to upgrade dilapidated infrastructure.

“We wouldn’t have any of these problems if nurses were paid well,” Dlamini says.

It’s a sentiment that was repeated by everyone Spotlight interviewed, and in line with the findings of multiple studies conducted over the past decade.

A 2023 study published in BMJ Open found low baseline government pay, the desire for financial freedom, and the need to pay off debts were the biggest drivers of moonlighting among doctors, rehabilitation therapists and professional nurses.

Today, nurses are caught in a financial squeeze. According to our analysis of DSPA data, below-inflation wage increases cumulatively wiped out about 8 percentage points of public sector nurses’ buying power between 2021 and 2023. After three years of losses, their pay has started to recover thanks to lower inflation and wage increases but ultimately, they’re still worse off than they were before the COVID-19 pandemic.

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Dlamini says many nurses also earn too much to qualify for government housing subsidies or NSFAS funding for their children’s education, yet they don’t earn enough to afford a bond or expensive university fees on their own.

Professional nurses typically progress through three tiers of seniority as they gain experience. They also get annual salary increases based on performance. The upper limit for the most experienced professional nurse (who isn’t a manager) is about R50 000 per month before tax, according to the DPSA’s latest salary data. This amount includes benefits such as pensions so take-home pay is lower.

Civil servants’ contributions to the state’s medical aid, the Government Employees Medical Scheme (GEMS), are outpacing their earnings. In two years, monthly contributions have jumped 23% in total, and members say they’re paying more for less.

Nurses aren’t legally required to join GEMS, but some government subsidies are tied to the scheme so opting out can also come at a cost.

There are reasons for hope. For the first time in two years, Treasury is adjusting tax rules so that inflation doesn’t eat into raises, helping people keep more of their take-home pay.

It’s hard to get a representative picture of what nurses are paid in the private sector. Leading public health researcher Laetitia Rispel, who chaired the process that led to government’s 2030 staffing strategy, explained that private sector partners are not obliged to share this information. They wouldn’t disclose what they paid nurses during the drafting of the staffing plan and withheld this information as confidential during the Competition Commission’s Health Market Inquiry (HMI).

According to the government’s staffing plan, reimbursement data shows that junior nurses tend to have higher salaries in the private sector, while private sector senior nurses may earn less than their counterparts in the public sector.

The coming retirement wave

A retirement crisis now looms over South Africa’s nursing profession, which remains the heart of the public healthcare system.

The latest data from the South African Nursing Council shows nearly half (48%) of the country’s nurses and midwives are aged 50 or older, with about a fifth already in the 60-69 year age bracket.

This exodus will be a massive loss of the nursing expertise and institutional knowledge essential for high-quality care. Their retirement could also exacerbate the existing nurse shortages, which already force nurses to the brink and often, out of public service.

This is more pronounced in rural areas, where exhausted nurses have described stress-related headaches, sleep disturbances and chest pains to researchers. One nurse at a psychiatric hospital in Limpopo told researchers she was responsible for 40 patients on a single night shift. Another collapsed in the ward while she was pregnant. “It’s a prison sentence,” a third nurse told the researchers.

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The researchers at the University of Venda argued that low wages could explain why some nurses steal and resell hospital supplies, and why they don’t consider it outright theft.

South Africa is also battling a critical shortage of nurse educators, an unintended consequence of the Occupational Specific Dispensation, which favoured clinical practice over teaching, and thereby created a pay gap that pushed faculty to transition into better paid clinical roles within government hospitals.

The health department’s staffing strategy until 2030 admits that South Africa needs to view nursing as an investment rather than an expense. It describes the many benefits of investing in nursing care which include economic growth and improved health services.

The document, drawn up in 2020, included measurable goals to address workforce issues by 2025, including a plan to meet a shortage of nurse educators and to train and employ up to 34 000 professional nurses and midwives.

The government hasn’t yet tracked progress against these targets, says spokesperson Foster Mohale, but a review by the Department of Planning, Monitoring and Evaluation is in the pipeline to guide the strategy’s remaining period.

In the meantime, the government is building a Human Resources for Health information system and registry and rolling out systems to track workforce indicators, he says. Coordination structures are also being strengthened, and occupational health and safety committees are coming to facilities around the country.

Money isn’t everything

In her 2024 presentation to a panel of experts tasked with getting buy-in from the broader health sector, called the Health Workforce Consultative Advisory Forum, Rispel warned that the 2030 human resource strategy could not be rolled out with an austerity mindset.

Research published in the journal PLOS One in 2025 backs this up. It suggests that professional nurses would give up moonlighting in exchange for a minimum 20% pay increase. That’s much lower than doctors (46%) and rehabilitation specialists (43%).

Modelling suggests however that if the government banned moonlighting, the state would need to bump salaries up by 50% to counteract an exodus among all three cadres.

The study found that a well-resourced environment is worth more than money to many nurses. Nurses would trade a large portion of their pay checks if it means finally having the resources to provide quality care.

Bitter laughter

Dlamini says she became a nurse to continue her mother’s legacy. “I saw how passionate she was. People would come up to her in the streets and say ‘sister, do you remember me, you helped me give birth’, she was so loved.”

She knows that she’s operating in the shadows of the system her mother served and recognises the danger of her own exhaustion. “We really should all be declaring,” she says.

But the feeling fades when she thinks of all the nurses who remain jobless on the one hand, and those who joined syndicates on the other.

It hurts to think about those moonlighting to pay for their children’s education or basic needs while others have opted to “order their skinny jeans through Tembisa hospital”, she says referring to rigged tender contracts that the hospital is mired in.

The two shop stewards laughed when Spotlight relayed Dlamini’s disgust with the hypocrisy of the system. That particularly South African, absurd kind of laughter that sits on the edge of anger and resignation.

“She’s right,” says Rabotapi. “How many more nurses could we have hired with that money?”

*Dlamini is not her real name. Spotlight has agreed to withhold her real name since we believe there is a risk she will be persecuted for speaking to the media.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags :

What the Law Actually Says About Migrants’ Right to Access Healthcare in SA

On By ModernMedia
Despite South Africa’s laws and policies, access to healthcare remains an issue, particularly for non-citizens. Photo by Hush Naidoo on Unsplash

By Teri Brown and Thembi Mahlathi

The media has reported several incidents where people were turned away at public healthcare facilities because they did not possess South African identity documents. As related cases slowly grind through the courts, Teri Brown and Thembi Mahlathi of SECTION27 connect the dots between what the law says and what people are experiencing.

Over the years, many migrants and undocumented people have reached out to SECTION27, where we both work, for assistance. These were often pregnant women, lactating mothers and children under six years, who were denied access to healthcare facilities.

Initially, it was easy to simply write a letter to hospital and clinic personnel where our clients were being denied access. But as time went on, the situation got significantly worse and more migrants were being denied access to public healthcare facilities. Writing letters and asking for meetings clearly wasn’t enough anymore.

We went to court and in April 2023 got an order in which the South Gauteng High Court held that important sections of the National Health Act applies to all pregnant women, lactating women and children under the age of six years, irrespective of their documentation status. This affirmed that in South Africa, they have the right to access free healthcare services at all public health establishments, including hospitals and clinics.

Public sector hospitals and clinics are required to assess the status of migrants and then apply a lawful means test to determine the healthcare services that can be offered to them. However, this does not appear to be done routinely. Instead, particular focus is often placed on South African identity documents, while other forms of documentation held by migrants are disregarded.

There have been incidents where entry to facilities such as Rahima Moosa Mother and Child Hospital in Coronationville and South Rand Hospital in Rosettenville and several clinics across Gauteng have been denied to people, including South African nationals who have the necessary documentation.

Furthermore, we are aware that to avoid being refused healthcare and to demonstrate the urgency of their need for treatment for themselves or their kids, migrants have sometimes been forced to disclose their HIV status – information which they would otherwise have kept private.

In mid-2025, we started receiving a surge of calls from clients complaining about not being able to enter public sector clinics that they were previously assisted at. They informed us that a group of people stationed outside these clinics requested their identity documents, and when they produced their documents confirming either their refugee status or asylum seeker status, they were unlawfully prevented from entering the clinics. These group of people explicitly told them that they should go to a private clinic for treatment or go back to their home country.

Thus, two years after the April 2023 court order, the denial of access to healthcare had worsened, as it was not only women and children who could not access clinics, but anyone who could not provide South African identity documentation. The situation was also exacerbated by the fact that it wasn’t just healthcare staff denying access anymore, but vigilante groups stationed outside healthcare facilities.

Despite the crisis being widely reported, the state failed to address it effectively. We had no choice but to go back to court, and again the court found in our favour.

In December 2025, the South Gauteng High Court ordered the state to take immediate and decisive action to end the obstruction of access to public healthcare facilities in Gauteng. The case was brought by the civil society organisations the Treatment Action Campaign, Doctors Without Borders, and Kopanang Africa Against Xenophobia (the applicants), all represented by SECTION27.

In this landmark judgment, Judge Stuart Wilson concluded that the state entities tasked with upholding the constitutional mandate to safeguard everyone’s right to access healthcare had failed to prevent the obstruction of access to public health facilities. Consequently, this failure was in violation of the constitutional rights of patients seeking care at the Yeoville and Rosettenville clinics.

Despite this court order, our monitoring found ongoing vigilante activity at the two clinics. The applicants then launched an urgent contempt application, heard in March 2026, arguing that the state had failed to fully comply with Judge Wilson’s court order.

Following this, a court ordered settlement agreement was reached with the Gauteng Department of Health and other respondents. Among other things, it required the authorities to take reasonable steps to ensure safe and unhindered access to the Yeoville and Rosettenville clinics, and to report on the implementation by 18 May 2026. It also makes provision to continue legal proceedings if necessary to enforce full compliance with Judge Wilson’s order.

The laws governing healthcare for migrants in South Africa

Taking a step back from this case, and its specific set of facts, it is worth remembering that South African law really does provide extensive protection to migrants who need to access healthcare services.

The right to access healthcare services is guaranteed by section 27 of our Constitution, which states that everyone has the right to have access to healthcare services, and that no one may be refused emergency medical treatment. The term “everyone” is not restricted to South Africans only. It includes everyone within the borders of South Africa, regardless of their nationality.

This right extends to all children living in South Africa under section 28(1)(c) of the Constitution. This guarantees all children access to basic healthcare services dependent on the availability of resources, to which they can never be completely denied.

After the Constitution, the most important piece of healthcare legislation relevant to migrants is the National Health Act (NHA). The NHA assists in giving effect to the constitutional right to basic healthcare services by outlining who can receive services at public clinics free of charge. It obligates the provision of free healthcare services to women who are pregnant or breastfeeding, or children under six. Moreover, the NHA requires that free primary healthcare be provided to those without medical aid. It also makes it clear that those working in healthcare cannot refuse any person emergency medical treatment.

Along similar lines, South Africa’s Refugees Act states that a refugee is entitled to full legal protection, which includes the rights set out in the Bill of Rights, except those reserved for citizens. The Act formally acknowledges that refugees are entitled to the same basic healthcare services and primary education that South African citizens receive. While the Act does not expressly cover undocumented migrants, it is grounded on the principle of non-discrimination, which supports equal access to essential services.

South Africa is also party to several international and regional human rights instruments that prohibit discrimination and guarantee equal access to healthcare for all. These include the African Charter on Human and Peoples’ Rights, the Convention Relating to the Status of Refugees, the International Covenant on Economic, Social and Cultural rights, the Convention on the Rights of the Child, and the Convention on the Elimination of All Forms of Discrimination against Women.

Why all this matters

The denial of healthcare services has significant impacts on many aspects of people’s lives. Migrants often become so desperate to receive care that they feel compelled to disclose their HIV status, which infringes on their rights, particularly the constitutional rights to privacy and dignity. It also creates feelings of stigma and discrimination, further marginalising people who are often already vulnerable.

There are also direct health consequences. Denying treatment to a migrant not only negatively impacts that person’s health it can also result in the continued transmission of infectious diseases to both other migrants and South Africans. For example, HIV and TB typically become non-infectious a while after someone starts treatment. Deciding not to treat someone ends up harming everyone. As untreated conditions worsen, it may require emergency medical attention that could have been avoided through early treatment. All of this places extra pressure on an already fragile health system – extra pressure that could be avoided by providing more migrants with healthcare services as soon as they need it.

The failure to provide healthcare services also affects migrants’ livelihoods and well-being. For those who run their own businesses, being unable to access treatment may prevent them from working altogether and could lead to them and other people, possibly South Africans, losing their jobs. Ultimately, this has a ripple effect on the country’s economy, job security, and perpetuates cycles of poverty and vulnerability.

At its heart then, this issue is about who we choose to be as a society. Turning people away at their most vulnerable moments erodes not only their dignity, but also their humanity and ours. In a country built on the values of equality and dignity, we cannot allow this attack on our basic humanity and decency to succeed. We are, and must be, better than that.

*Brown is a legal researcher and Mahlathi is a paralegal with SECTION27. In the court case discussed in this article, SECTION27 represented the Treatment Action Campaign, Médecins Sans Frontiers, and Kopanang Africa Against Xenophobia.

Note: Spotlight is published by SECTION27, but is editorially independent – an independence that the editors guard jealously. Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Republished from Spotlight under a Creative Commons licence.

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Categories : Respiratory DiseasesTags :

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

On By ModernMedia
Photo by Andrea Piacquadio on Pexels

By Elri Voigt

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

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

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

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

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

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

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

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

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

Early start

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

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

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

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

Two potential scenarios

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

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

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

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

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

What we know about sub-clade K

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

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

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

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

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

Trends seen in previous flu seasons

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

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

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

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

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

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

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

Flu vaccination uptake in South Africa remains low

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

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

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

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

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

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

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

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

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

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

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

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

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

The potential of next generation flu vaccines

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

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

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

Republished from Spotlight under a Creative Commons licence.

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Categories : Expert Opinion Healthcare Politics and RegulationsTags :

As NHI Stalls, the Real Debate Is About Trade Offs

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

By Thoneshan Naidoo

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

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

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

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

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

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

But solidarity comes with trade-offs.

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

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

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

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

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

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

And they are taking place in a system under pressure.

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

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

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

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

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

Neither is true.

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

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

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

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

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

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

Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Republished from Spotlight under a Creative Commons licence.

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Categories : Mental HealthTags :

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

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

By Marcus Low

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

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

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

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

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

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

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

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

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

Increasing, but still very low antidepressant usage

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

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

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

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

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

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

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

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

Republished from Spotlight under a Creative Commons licence.

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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.

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

From policy ambition to implementation

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

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

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

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

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

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

Disclosure: Spotlight receives funding from the Gates Foundation but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Republished from Spotlight under a Creative Commons licence.

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.”