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

On By ModernMedia
The District Health Programme Grant is a mechanism for funding the country’s public health efforts, particularly relating to HIV, TB, and other communicable diseases.

By Russell Rensburg

District managers in South Africa’s public healthcare system currently have to juggle funding from multiple government budget lines, each with different strings attached. To improve district health services, we urgently need to simplify and integrate these funding flows, argues Russell Rensburg.

In his State of the Nation Address this year, for the first time in a long time, President Cyril Ramaphosa focused on the broader determinants of health, delivering the strongest message yet around the importance of prevention.

This included signalling reforms around the taxation and regulation of alcohol as well as announcing broad initiatives to improve child health through good nutrition.

And his announcement that government will be rolling out the HIV prevention injection, lenacapavir, means that South Africa stands at the cusp of a massive healthcare transition. The six-monthly injection will be a game-changer in the country’s ongoing fight against HIV.

His efforts must be applauded.

But to deliver on this, Ramaphosa will need a functioning district healthcare system. The challenge, however, is that the district healthcare system often functions in name, but not in practice. This disconnect is mostly due to how district-level services – and healthcare in general – is funded.

In short, we ask for integrated healthcare services in a system built on siloed funding streams. We task district managers with coordinating care, but the budgets they depend on are split across the provincial equitable share, multiple conditional grants, and hospital-level allocations.

Health is funded from national revenue through two streams: the national department of health and the provincial equitable share. The equitable share, which funds healthcare and education, is calculated using several factors including population size, use of services and potential unmet and future needs. The allocations are unconditional allowing provinces to determine all the allocations relative to provincial realities, cost pressures and needs. With national funding, 85% is transferred to provinces through defined use conditional grants to fund strategic priorities. The challenge is that in recent years these grants have become transfers to provinces with poorly managed conditionalities resulted in fragmented healthcare.

One way to fix these challenges is to consolidate all district health funding — including district hospitals — into a single, nationally coordinated expanded District Health Programme Grant. This reform would align the system with the National Health Act, strengthen accountability, and prepare us for the healthcare transitions ahead.

This shift is not about centralising services. It is about aligning authority with responsibility, and aligning money with the legal design of the health system. Provinces would remain responsible for service delivery. But national government — as required by the Act — would finally have a coherent instrument to guide, monitor, and support the district health system.

A fragmented system

Twenty-three years ago, the National Health Act set out a detailed framework for how healthcare should be structured in the country. Health policy norms and standards are set nationally. Provinces are responsible for coordinating and providing technical and operational support to districts. Crucially, the act locates the delivery of health services within the district health system, which is mandated to plan, coordinate and deliver comprehensive primary healthcare services closest to where people live.

Where the National Health Act falls short, is in providing guidance on how these powers and responsibilities would be financed.

Currently, district health services are funded through three streams:

  • The provincial equitable share, allocated nationally to each province based on population size and demand for health services. This covers most primary healthcare services and all district hospitals.
  • The District Health Programme Grant, which focuses on HIV, TB, community outreach, and some primary healthcare enablers.
  • And thirdly, a patchwork of other conditional grants for training, infrastructure, oncology, and digital systems.

The challenge with this approach is that each of these funding streams has its own rules, reporting requirements, and political histories. None of them were designed to work together.

Making the case for consolidation

Twenty odd years ago, the case for split funding streams made more sense. In the early 2000s, South Africa faced an overwhelming HIV epidemic. We needed targeted programmes, ringfenced funds, and rapid scale-up. Conditional grants was an instrument, that in a specific context, helped save millions of lives. But this instrument has now hardened into permanent architecture. And unfortunately, it is not fit for today’s health challenges.

South Africa is at a critical moment. The population is ageing, rates of non-communicable diseases like diabetes and hypertension are rising, HIV and TB require lifelong, coordinated management, and the pace of technology is rapidly reshaping healthcare.

The system that was built 20 years ago simply cannot carry us through the next 20 years.

At the same time, South Africa’s health budget is tightening. Despite a small increase in last year’s budget, the trend over the last decade or so is clearly toward having to do more with less.

We cannot expect the system to meet these growing demands while the foundational governance and funding architecture is no longer fit for purpose.

How it could work

Under an expanded District Health Programme Grant, national government – as the law mandates – would set the healthcare package, standards, indicators, and information requirements. Provinces would continue to run services, hire staff, manage facilities, and account for performance in line with the provisions of the National Health Act. And districts would finally have a budget that reflects their actual responsibilities.

In simple terms, this means that the expanded district health programme will be structured as a conditional grant. It will be informed by a nationally defined package of district health services, developed in consultation with provinces. Provincial allocations will be informed by strategic priorities and service needs such as essential health services, reproductive, maternal and child health services, as well as infectious diseases and non-communicable diseases. The National Department of Health will be responsible for managing the grant conditions with stronger accountability mechanisms to ensure alignment with strategic aims and constitutional responsibilities. Provinces will continue to control human resources, service delivery networks and district variations. This is what the National Health Act intended.

This is the model used by many countries that have successfully strengthened district health systems: national sets the rules and maintains oversight, while provinces or local governments handle delivery.

As already noted, South Africa does have the legal architecture for this. We just don’t have the financial mechanisms in place to match it.

In practical terms, such reforms will mean that for the first time, a district could budget for clinics, ward‑based outreach teams, HIV and TB services, chronic disease management, district hospitals, laboratory and pharmacy systems, emergency medical services linkages, and digital and information systems.

The artificial lines between primary healthcare and district hospitals would disappear. The system would fund itself as the Act intended, as one. District hospitals would no longer be expected to manage pressures created by primary healthcare gaps they have no control over.

There are several other benefits, such as improved accountability, an easier adaptation to demographic and epidemiological transitions, and more efficient use of limited budgets. These ultimately all develop a realistic pathway to universal health coverage.

A governance correction, not a revolution

There may be concerns that consolidating funding into a single grant means taking power away from provinces. The reality, however, is that this reform would restore coherence, not remove authority.

South Africa has spent decades speaking about equity. This is a practical way to make equity real.

When we underfund the district health system in structure, we undercut the very people who rely on it most. These are rural communities, working class households, and people managing chronic and infectious diseases who require continuity of care, not bureaucratic fragmentation.

A unified District Health Programme Grant will not solve every problem in our health system. But without it, we will continue asking a fragmented system to produce cohesive outcomes, and blaming managers and health workers when it inevitably cannot.

It is time to give the district health system the financial foundation it has always needed. Only then can we build the health system people in South Africa deserve.

*Rensburg is director of the Rural Health Advocacy Project and project director for the TB Accountability Consortium.

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

Republished from Spotlight under a Creative Commons licence.

Read the original article.

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

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

By Andy Gray

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

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

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

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

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

Never the twain shall meet

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

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

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

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

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

Private sector – not entirely transparent

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

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

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

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

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

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

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

So, what’s not transparent?

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

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

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

New concerns – failure to declare an SEP

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

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

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

The unknown unknown

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

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

Has the NDP 1996 been implemented?

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

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

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

Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : Healthcare Politics and RegulationsTags :

SA has a “Bogus Doctor” Problem

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

By Elna Schütz

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

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

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

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

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

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

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

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

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

A substantial problem

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

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

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

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

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

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

Risk to patients

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

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

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

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

Knowing the signs

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

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

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

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

Processing the problem

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

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

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

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

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

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

Republished from Spotlight under a Creative Commons licence.

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How WhatsApp is Being Used to Train Healthcare Workers

On By ModernMedia
Photo by Thirdman

By Sue Segar

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

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

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

Drug-drug interactions

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

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

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

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

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

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

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

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

Doing the research

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

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

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

Testing the efficacy of short training sessions

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

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

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

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

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

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

Working with the department of health on 6MMD

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

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

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

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

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

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

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

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

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

Department of Health backing

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

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

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

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

Republished from Spotlight under a Creative Commons licence.

Read the original article.

Categories : Healthcare Politics and RegulationsTags :

Spotlight’s Top 9 Health Stories to Watch in 2026

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

19th January 2026 | By Marcus Low

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*Low is the editor of Spotlight. 

Republished from Spotlight under a Creative Commons licence.

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Categories : Expert Opinion Respiratory DiseasesTags :

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

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

By Janet Giddy

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

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

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

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

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

If COVID-19, why not TB?

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

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

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

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

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

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

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

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

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

‘We are all at risk’

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

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

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

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

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

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

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

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

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

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

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

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

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags :

EDITORIAL | What has Actually Happened on NHI This Year?

On By ModernMedia

By Spotlight

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

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

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

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

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

To the courts then 

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

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

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

Other NHI developments 

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

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

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

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

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

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

Not the only solution 

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

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

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

Republished from Spotlight under a Creative Commons licence.

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Categories : CancerTags :

SA Has Relatively High Anal Cancer Rates, but We Rarely Screen for It

On By ModernMedia
People living with HIV are at an increased risk of developing anal cancer, particularly if they have compromised immune systems. Photo by Lorenzo Turroni on Unsplash

By Elna Schütz

South Africa has the world’s largest population of people living with HIV, which both heightens the risk of anal cancers and their severity. However, neither the collection of data nor the efforts for prevention and screening are in line with the likely impact. Experts say significant change is needed.

“Almost everyone has an anus,” Dr Daniel Surridge, a colorectal surgeon at Joburg Colorectal, says with a smile. He is one of a group of specialists trying to draw attention to arguably one of the most neglected areas in cancer.

“We’re quite a weird niche group who talk about bums all day, but most people are really in denial that they have an anus,” jokes Dr Tim Forgan, another colorectal surgeon, working in the private and public sector in Cape Town.

“It’s such an essential part of your daily life and you need your anus,” adds Dr Mark Faesen, specialist gynaecologist with the Clinical HIV Research Unit (CHRU), who runs an anal cancer screening clinic at Helen Joseph Hospital in Johannesburg, as far as we know, the only one in the country.

The stigma surrounding this particular body part, unfortunately, does no one any favours when it comes to cancer awareness and treatment.

A tricky hidden cancer

Anal cancers occur in the last few centimetres towards the external opening of the rectum. They can be associated with rectal, colon, or genital issues.

Professor Michael Herbst, health specialist consultant for the Cancer Association of South Africa, explains that the vast majority of these cancers are anal squamous cell carcinomas, meaning they develop in the skin cells of the anal canal.

Most anal cancers are caused by Human Papillomavirus (HPV), a virus that also causes most cases of cervical cancer.

“Patients and doctors often misdiagnose those early symptoms as haemorrhoids,” Herbst says, explaining that the disease is asymptomatic at first. Later, it may present with itching, discharge, bleeding or a palpable lump.

Ideally, a diagnosis is made of a pre-malignant lesion, which is a fairly flat, slightly dark growth. This can be found through a rectal exam or smear. A biopsy under anaesthesia may be needed to confirm the diagnosis.

Premalignant lesions can be treated topically if caught early. Otherwise, the skin may have to be surgically removed, which is often a difficult and risky surgery in this part of the body.

Once a lesion has progressed to cancer, treatment involves high doses of chemotherapy and radiation, which Surridge says is intense and only treats about half of patients effectively. “The rest go to a surgery where you have to remove the anus along with the rectum and put in a permanent colostomy bag,” he says.

In comparison to the rectal and colon cancers that Surridge sees in his work, he describes anal cancers as less predictable and more aggressive, with painful consequences. “It’s going to hurt like hell,” he says. “It stinks like you’re rotting from the inside, so no one wants to come near you.”

Anal cancers are also particularly resistant to chemotherapy, Surridge says, and run the risk of spreading through the lymph system, leading to a dismal outcome, possibly leading to death.

People living with HIV are at an increased risk of developing anal cancer, especially if they have compromised immune systems.

Faesen says that internationally, in the general population, the incidence of anal cancer is around 2 per 100 000 people per year. “If you’re HIV positive long enough, so over the age of 45, the risk is 20 to 40 per 100 000 per year,” he says. For men who have sex with men, the incidence can be as high as 60 or 130 per 100 000.

Those with HPV and patients with immune systems not working as well as they should, such as those who have received an organ transplant, are at risk. Furthermore, groups who engage in high-risk sexual activities, like men who have anal sex with multiple male partners, should be aware of the risk. However, sexual orientation and anal sex do not directly lead to an increase in anal cancer risk.

Rare but not that rare

Anal cancer may be considered a rare cancer, but the few local experts on it see it as a concerning cancer because of South Africa’s high number of people who are at increased risk.

“Anal cancer is strangely common in South Africa. It’s not extremely common, but it is reasonably common,” says Forgan.

The National Cancer Registry’s latest numbers, from 2023, has the cancer reported in around 300 women and 220 men, making up less than 0,7% of reported cancers. A recent analysis of the registry’s numbers found that the cancer’s incidence has significantly increased between 1994 and 2021. The paper found that younger black women and older white women were most likely to get the cancer. A study at the University of the Witwatersrand in 2023 found that three-quarters of their anal cancer cohort were female and 80% were HIV positive.

“We don’t actually know the true incidence in South Africa,” says Dr James Pattinson, Head of Colorectal Surgery at Chris Hani Baragwanath Academic Hospital, explaining that the disease is likely under-reported. Anecdotally, he says the cancer seems common in Gauteng. He says his unit alone sees around 100 new cases of anal cancer a year, making up around 30% of new reported colorectal cancers.

Surridge says it is getting more common, and “it is certainly raging through Gauteng”.

The challenges

The doctors agree that the reported numbers are likely lower than the real prevalence and that many cases could be avoided or caught early with intervention. A key factor is the lack of education and patient hesitancy to get tested. “The natural stigma and embarrassment associated with anal conditions cause patients to wait until the condition is severe before seeking medical help,” Pattinson says.

“The lack of awareness doesn’t stop at the door of the Department of Health,” Faesen says. He laments that few healthcare workers are well-informed about this cancer. This leads to misdiagnoses and problems being missed. This is aggravated by financial and resource constraints. But, he says, this is not a “blame game”, since the greater awareness of anal cancer is fairly new.

For instance, the International Anal Neoplasia Society’s consensus guidelines for anal cancer screening were only released in early 2024. Faesen explains that while cervical cancer screening was popularised internationally around the 1960s, it was only a study published in the New England Journal of Medicine in 2022 that found that treating lesions substantially lowers the risk of anal cancer, that heightened the interest in screening.

In that study, of over 4 000 people, progression to anal cancer was more than 50% lower in people who received treatment for precancerous lesions than in people who did not. The study provided a compelling rationale for increased screening, since it is only through finding precancerous lesions in the first place that they can be treated and progression to cancer be prevented.

Reaching the level of common-place awareness for anal screening that there is around cervical pap smears is still a while away. “It took 50 to 60 years to get there, but we’ve just started,” Faesen says. “We are at the absolute beginning of anal cancer awareness.” He does however note that the incidence of anal cancer in some South African populations is already much higher than that of cervical cancer when routine screening for that was started.

What to do

The lack of screening for anal cancer is one clear issue that needs to be addressed. “Hopefully, we can demonstrate with more and more screening that there is a need for it,” Faesen says. He hopes that this will catch the problem before it progresses to a serious disease in more patients.

However, Pattinson notes that screening in other countries has been historically focused on high-risk populations such as men who have sex with men. “This is obviously not feasible in South Africa, as high-risk individuals are the millions of people living with HIV.”

Screening could potentially be focused on certain sites, like HIV-specific clinics or doctors who particularly work with HPV and cervical screening. Expanding screenings for high-risk groups to include anal would not be incredibly expensive but would add an extra burden on staff, Forgan says. “And it’s a very easy thing to screen for. You just have a look.”

There is also a preventative solution, the HPV vaccine. A two-strain form of this vaccine is already offered to girls aged 9 to 12 years old by the Department of Health. This does not cover other strains and is mostly focused on cervical cancer.

Surridge says that focusing on vaccinating only girls means boys aren’t protected, and creates a possible lag in protection against anal cancer. He says the vaccine, ideally one with more strains, if possible, should be given to as many people as possible.

“If you’re in a higher risk group, like those (who are) immuno-suppressed, with HIV, or solid organ transplant recipients, you should be vaccinated,” Forgan says. “Then you wouldn’t need a screening programme, per se, because you had prevented it from happening.”

Beyond this, increasing education around the disease and eventually instituting local guidelines would be crucial.

The National Department of Health did not respond to questions from Spotlight about their plans relating to anal cancer.

Republished from Spotlight under a Creative Commons licence.

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Categories : HIV Obstetrics & GynaecologyTags :

Integrating Health Services for Mom and Baby Could Reduce Clinic Visits by Half

On By ModernMedia
After birth, moms and babies are required to visit healthcare facilities for essential services like immunisations, postnatal care and HIV testing. Photo by William Fortunato on Pexels

By Elri Voigt

In South Africa, many mothers and their babies have to visit the clinic more than 10 times in the first six months of the postnatal period. Early findings from an ongoing implementation science project suggests we can get this down to five. The hope is that the new approach will also help reduce HIV transmission from mothers to their babies. 

Over the last two decades, South Africa has taken huge strides in reducing HIV transmission from mothers to their babies (often called vertical transmission).

Maternal deaths from non-pregnancy-related infections have decreased, because more women are taking HIV treatment, and HIV rates among babies at birth have also gone down. This has all been possible largely because of integrating HIV services with our antenatal services, Dr Jeanette Wessels, of the University of Pretoria’s Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies, told delegates at the recent Southern African HIV Clinicians Society (SAHCS) Conference.

However, a closer look at the data shows us that while vertical transmission at or before birth has come down dramatically, HIV transmission in the months after birth remains alarmingly common. This happens particularly when the mother contracts HIV in this period and the virus is then transmitted to her baby before she is diagnosed, or before the virus can be brought under control with antiretrovirals. As Wessels puts it, “our next frontier to tackle is the breastfeeding period”.

During the antenatal period (before birth), pregnant women are offered HIV tests and prevention pills or HIV treatment when they visit clinics for their pregnancy check-ups. However, during the postnatal period (after birth), HIV services are not integrated in the same way. This fragmentation of care after birth is a key driver of vertical transmissions, suggests specialist paediatrician Dr Nthabiseng Serudu-Nageng. The thinking is that the fragmentation and high number of clinic visits makes it less likely that new HIV infections in mothers will be picked up before the virus can be transmitted to their babies and that it makes it less likely that new mothers will take the HIV prevention pills or HIV treatment they might need.

Spotlight previously reported that, according to the latest estimates from Thembisa – the leading mathematical model of HIV and TB in South Africa – of the roughly 7 200 babies who contracted HIV in the country from mid-2023 to mid-2024, only about 2 500 got HIV before or at birth. This means that about 4 700 babies got HIV in the months after birth, and while some of these mothers were on antiretroviral therapy, according to the Thembisa estimates, the majority of mothers had not been diagnosed with HIV yet. Meaning a contributing factor to some of these infections is likely that many of these mothers got HIV after the birth of their babies and were unaware of it.

Wessels told delegates that around 75% of mother-to-child transmission of HIV is happening during breastfeeding, and just over one third (35%) of those are due to new HIV infections in the mother. She added that about 80% of those new infections in babies after birth happen in the first six months.

It is important to realise that in terms of absolute numbers, HIV transmission during the breastfeeding period has gone down, but proportionally more babies are getting HIV after birth, explained Professor Ute Feucht, the Director for the University of Pretoria’s Research Centre for Maternal, Fetal, Newborn and Child Health Care Strategies. Feucht is also the Community Paediatrician in the Tshwane District Clinical Specialist Team at the Gauteng Department of Health.

Clinic visits can be halved

To improve care in the postnatal period, researchers in Gauteng have launched an ambitious implementation science project called Sihamba Kunye. Their key idea is that clinic visits for mother and baby can be much better integrated and optimised. This could make it more likely that mother and baby will attend all required clinic visits and get all the healthcare services they need. The project is funded by the Gates Foundation.

During the postnatal period, said Wessels, a mother may have to come to the clinic up to 11 or 12 times in the first six months. This can be to get her baby to the necessary visits for immunisations, as well as family planning, to pick up HIV treatment or prevention pills or postnatal care for herself. Wessels was presenting early observations from the study at the SAHCS conference.

Commenting on this, Feucht, who is the study’s principal investigator, told Spotlight: “That is twice a month, and yes, with a newborn baby!”

To make matters worse, throughout these many visits, mothers and babies are often seen separately, which isn’t optimal since, as Serudu-Nageng pointed out, “whatever affects the mother directly impacts her baby, so integrating their care is essential”.  She is the study’s consultant paediatrician.

“One of the biggest challenges mothers face is having to come to the clinic many times in the first six months. This has a huge impact: it affects food security, especially for unemployed mothers, its transport costs, its time away from work or home, and long waiting hours at the facility. Each visit comes with an emotional and financial cost,” said Serudu-Nageng.

“Through the Sihamba Kunye project, we are addressing this [challenge] by aligning and coordinating the mother and baby’s visits so they can be seen together, on the same day and ideally at the same service point,” she said. “This reduces the number of visits, saves time and cost for the mother, eases the workload for the facility because it means less feet through the clinic all while maintaining quality care for both mother and baby.”

By coordinating these different visits, the total number of times a mother and baby might need to go the facility is reduced to only five visits.

How it works

The researchers conducted time-and-motion studies – where industrial engineering students from the University of Pretoria followed patients around with stopwatches to time how long it took them to move through the clinic from arrival to exit. They also conducted interviews with mothers and infant pairs, had consultations with facility managers, and conducted workshops with healthcare workers, as well as created curated resources and tools to assist with the transition to offering integrated care.

Integration of services was classified into two levels, depending how much the services could be streamlined, said Serudu-Nageng. Level two integration means that a mom and her baby are seen on the same day, but at different parts of the facility and likely by different nurses. Level three integration means they are seen together, on the same day, by the same nurse.

“We worked closely with facility managers, sub-district programme managers and clinicians to redesign processes and adapt the model to fit each facility’s realities,” she said.

The time-and-motion studies helped identify bottlenecks and improve the flow and efficacy at the clinics, Serudu-Nageng said. One big time waster was that if a mom comes in with her baby and the healthcare staff only draw baby’s file but later see mom also needs care, she’ll have to go back to get her own file. To resolve this, the project recommends drawing both mom and baby’s files when they visit the facility, regardless of the reason for the visit.

One major component of integrating care, Serudu-Nageng said, was task-shifting. This is to ensure that professional nurses have the time to spend doing clinical consultations with mom and baby together, since their consultation time has essentially doubled. This means designating tasks like checking vital signs, weighing, giving immunisations and vitamin A and deworming to support staff, leaving professional nurses to do tasks only they are qualified to do.

“[T]he professional nurses can be used for other things like clinical decision making and we can rather delegate work that doesn’t require clinical decision making to lower cadres of nurses of staff,” she said. “Together, these efforts have helped facilities streamline workflow, strengthen teamwork and deliver this integrated postnatal care package for both mothers and babies.”

Another thing the researchers did was to compile two important tools that pulled together information from all the relevant national guidelines for primary healthcare – like the HIV, TB, ideal clinic and immunisation guidelines – and putting them together in one place called the the First 1000-day Roadmap. This is used alongside an Integration Wheel that helps nurses coordinate the different visits moms might need to come to the clinic for.

Wessels in her presentation explained that the roadmap has different sections categorised according to the type of visit mom and baby are at the clinic for. She gave the example of the 10-week visit, where babies normally receive some of their key childhood immunisations. One section of the roadmap will include “all the care needed for the mom, her general postnatal care, nutrition, VTP [Vertical Transmission Prevention] and screening like TB screening, STIs, mental health, her contraception and extra care”. The other section will cover all the things the baby will need.

The roadmap is used alongside the Integration Wheel, which is designed like a pregnancy wheel. The front of the wheel can spin to the visit the mom and baby are at the clinic for. “It outlines [among other things] what you do for an HIV positive mom, for an HIV negative mom, what contraception do you get every mom,” Wessels said. At the back, the wheel has information on the different visits mom and baby would still need to come to the clinic for and helps nurses align those visits.

The front of the Integration wheel can be spun to the specific visit mom and baby are at the clinic for and help align their next visits to reduce the number of times they have to come to the facility. Source: Screenshot from Professor Ute Feucht’s presentation on the Sihamba Kunye Project at the 2025 SA AIDS conference.
The back of the Integration wheel shows nurses everything they need to do for both mom and baby, depending on their HIV status, baby’s age and mom’s family planning needs and postnatal care. Source: Screenshot from Professor Ute Feucht’s presentation on the Sihamba Kunye Project at the 2025 SA AIDS conference.

With these resources, according to Wessels, nurses at the participating facilities are able to align mom and baby’s visits from their six-day postnatal visit and can reduce those visits to only five in the first six months.

What’s next?

The response to the project has been very positive and created a bit of a “snowball effect”, Feucht said. “The district has actually been asking us, when can we go to the rest [of the clinics in Tshwane]?”

The first phase, she added, was to figure out what is possible in terms of integrating care and how can it be done. “[T]he next step is then taking that toolkit out to the other provinces as well.”

The research team hopes to have several publications showcasing their findings ready to present at key health conferences next year. But they also hope to see the model being more widely used in the future.

“It’s got potential to transform the postnatal period and make it as good as the antenatal period,” Serudu-Nageng said. “[I]ntegrating care and putting the patient at the centre will really, really, be great for outcomes, but for mom and baby as well.”

“Based on my experience, this approach is highly feasible within the broader public healthcare system because it builds on existing structures and staff,” she added. “It is practical and scalable, and we are hopeful that it will serve as a proof of concept for future scale-up across South Africa’s public health system.”

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 and subject to the Press Code.

Republished from Spotlight under a Creative Commons licence.

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Categories : Expert Opinion Healthcare Politics and RegulationsTags :

#InsideTheBox with Dr Andy Gray | Where Are We on the Road to More Coherent Cannabis Regulation?

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

By Andy Gray

There has been much confusion and misunderstandings about how cannabis and associated products are regulated in South Africa, with government’s own missteps adding to the uncertainty. In his last #InsideTheBox column for the year, Dr Andy Gray clearly sets out the current legal and regulatory situation and where we’re heading.

There is a fundamental assumption that underpins much of the legislation relating to pharmacologically active substances, especially those that have neuropsychiatric effects. Some are recognised as having legitimate medicinal uses, in humans and/or animals, and so are regulated as medicines. Others are deemed to have no legitimate medicinal uses, and so their possession and use is prohibited or even criminalised. Some of these substances are obtained from natural sources, such as plants or fungi, and some have been recognised and used since antiquity, precisely for their effects, both for pleasure and ritual.

Cannabis is a prime example, which grows on all continents other than Antarctica and has been used for a wide variety of purposes, both for its pharmacological actions and for its physical attributes, as a source of fibre and nutrition.

South Africa has a long and complex history with regard to cannabis. It was the South African government which proposed to the League of Nations Dangerous Drugs Committee in 1923 that cannabis be subjected to international regulation. That status remains in place, in terms of the Single Convention on Narcotic Drugs, 1961, to which South Africa is a signatory. Schedule I to the Convention, which is maintained by the International Narcotics Control Board, includes “the flowering or fruiting tops of the cannabis plant”, as well as “the separated resin, crude or purified, obtained from the cannabis plant”. Parties to the Convention are required to “adopt such measures as may be necessary to prevent the misuse of, and illicit traffic in, the leaves of the cannabis plant”. Cultivation of cannabis is to be regulated in the same manner as that applied to opium poppies, but with an important caveat: “This Convention shall not apply to the cultivation of the cannabis plant exclusively for industrial purposes (fibre and seed) or horticultural purposes.”

As a result, cannabis was for many years listed as a Schedule 7 substance in terms of South Africa’s Medicines and Related Substances Act, 1965, and also included in the “Undesirable Dependence-Producing Substances” in terms of the Drugs and Drug Trafficking Act, 1992. While exceptional access was allowed for research, analysis or use by a particular patient, substances in those categories could not ordinarily be possessed or sold.

That entire legal construct was overturned by a 2018 Constitutional Court judgment which declared the relevant sections of both laws unconstitutional “to the extent that they criminalise the use or possession in private or cultivation in a private place of cannabis by an adult for his or her own personal consumption in private”. The court allowed legislators a period of 24 months to remedy the situation.

THC and CBD

Although the cannabis plant contains over 100 identifiable chemical components, two are of particular importance. Tetrahydrocannabinol (THC) is the psychoactive component, whereas cannabidiol (CBD) is not psychoactive. At higher doses, cannabidiol has been shown to be effective in the management of some paediatric epilepsy syndromes.

The first change made to comply with the Constitutional Court judgment involved moving THC to Schedule 6 (alongside morphine, for example) and CBD to Schedule 4 (as a prescription medicine). The Schedule 6 inscription also included an exception to allow adult use, echoing the wording in the court judgment. The control measures applicable to a Schedule 6 substance (such as the need for a prescription) do not apply when “raw cannabis plant material is cultivated, possessed and consumed by an adult, in private for personal consumption”. The Schedule 4 inscription also allowed for low-dose CBD products (containing a maximum of 20mg per day and 600mg per pack) to be regulated as a complementary medicine, provided the labelling made only a low-risk claim (a general health enhancement or health maintenance claim or a claim of relief from minor symptoms).

The South African Health Products Regulatory Authority (SAHPRA) has issued just over a hundred licences for the cultivation and export of cannabis for medicinal purposes. These licences are for the preparation of the raw material from which medicines could be made, but no THC-containing products have yet been registered in South Africa. SAHPRA does not report on the number of section 21 permits issued to individual patients seeking access to THC-containing medicines, nor on the sources of unregistered medicines approved in that manner (section 21 permits allows for access to medicines not registered by SAHPRA).

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SAHPRA’s cannabis cultivation permits do not allow the sale of cannabis products directly to the public. SAHPRA has not issued licences to any retail outlets for cannabis or cannabis-containing products. Retail outlets claiming to be licensed “dispensaries” are therefore operating illegally.

In 2024, the Schedules were again updated, with this exception inserted: “in raw cannabis plant material cultivated and possessed in accordance with a permit issued in terms of the Plant Improvement Act (Act 11 of 2018) and processed products manufactured from such material, intended for agricultural or industrial purposes, including the manufacture of consumer items or products which have no pharmacological action or medicinal purpose”.

The Plant Improvement Act, 2018, is intended to regulate the propagation and sale of particular plants, setting quality standards for economically important varieties, such as wheat. In November 2025, the Minister of Agriculture, Land Reform and Rural Development issued regulations in terms of this Act, setting a THC limit of 2% for the leaves and flowering heads of cannabis plants considered to be “hemp” (low-THC cannabis). That action provides the clarity required to interpret the Schedules to the Medicines Act and creates a process for the issuing of “hemp” permits for the cultivation and sale of low-THC cannabis for industrial applications.

‘A work in progress’

Bringing the Drugs and Drug Trafficking Act into alignment with the Constitutional Court judgment has been far more complex than the Medicines Act and is still a work in progress. The section of the Drugs Act which enabled the Minister of Justice to make schedules listing substances in different categories was found to be unconstitutional in 2020. Future changes to the schedules will require an Act of Parliament. Distinct from the Schedules to the Medicines Act, these lists designate which substances, for example are considered “Undesirable Dependence-Producing Substances”, the possession of which may be a criminal offence.

Instead, the Minister of Justice and Correctional Services tabled a separate Bill in 2019, which was finally passed as the Cannabis for Private Purposes Act, 2024. While that Act has been assented to by the President, it has not yet been promulgated and no regulations have been issued. The legislation is therefore not yet in operation. Regulations are needed, for example, to specify the amounts of cannabis that can be cultivated, possessed or transported. Most importantly, though enabling the possession or cultivation of cannabis in a private place, and therefore personal consumption by an adult, the Act does not enable the commercialisation of cannabis for “recreational” or “adult use”, as is the case with alcoholic beverages or tobacco products.

South Africa’s Cannabis Master Plan, which envisages three separate value chains, covering medicinal cannabis, hemp, and adult use, is now being driven by the Department of Trade, Industry and Competition (DTIC). The DTIC plans to submit a Hemp and Cannabis Commercialisation Policy to Cabinet by April 2026 and to table an Overarching Cannabis Bill by mid-2027.

The 2018 Constitutional Court judgment overturned almost a century of established practice. While the evidence for the medicinal value of cannabis and specific cannabinoids is still scanty, the assumption that such products have no medicinal value at all is no longer tenable. As with all pharmaceutical products, this is a highly regulated market with high barriers to entry.

An industrial market for low-THC cannabis is already well established and the necessary steps to enable its growth are now in place. However, the ill-informed ban on the inclusion of any cannabis components in foodstuffs, which was issued and then rapidly repealed in 2025, is indicative of the lack of coherence in government policy. The challenge remains the commercialisation of an adult use market, and whether that will enable the involvement of the small-scale rural growers who have traditionally met demand for the product.

Cannabis policy therefore remains in flux, and the entire legislative process has been marked by missteps, missed steps, reverses, ambivalence and confusion. Some pieces of the picture are in place, but others remain uncertain or incomplete.

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

Disclosure: Gray serves on three technical advisory committees at the South African Health Products Regulatory Authority and previously chaired the Cannabis Working Group.

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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