Tag: Spotlight

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Inside the SAMRC’s Race to Rescue Health Research in SA

On By ModernMedia
Mycobacterium tuberculosis drug susceptibility test. Photo by CDC on Unsplash

By Catherine Tomlinson

Health research in South Africa has been plunged into crisis with the abrupt termination of several large research grants from the US, with more grant terminations expected in the coming days and weeks. Professor Ntobeko Ntusi, head of the South African Medical Research Council, tells Spotlight about efforts to find alternative funding and to preserve the country’s health research capacity.

Health research in South Africa is facing an unprecedented crisis due to the termination of funding from the United States government. Though exact figures are hard to pin down, indications are that more than half of the country’s research funding has in recent years been coming from the US.

Many health research units and researchers that receive funding from the US National Institutes of Health (NIH) have in recent weeks been notified that their grants have been terminated. This funding is being slashed as part of the efforts by US President Donald Trump’s administration to reduce overall federal spending and end spending that does not align with its political priorities.

Specifically, the administration has sought to end spending supporting LGBTQ+ populations and diversity, as well as equity and inclusion. As many grants for HIV research have indicators of race, gender, and sexual orientation in their target populations and descriptions, this area of research has been particularly hard hit by the cuts. There have also been indications that certain countries, including South Africa and China, would specifically be targeted with NIH cuts.

On 7 February, President Donald Trump issued an executive order stating that the US would stop providing assistance to South Africa in part because it passed a law that allowed for the expropriation of land without compensation, and separately because the South African government took Israel to the International Court of Justice on charges of genocide in Gaza.

Prior to the NIH cuts, some local research funded through other US entities such as the US Agency for International Development (USAID), and the Centers for Disease Control and Prevention (CDC) were also terminated.

How much money is at risk?

“In many ways the South African health research landscape has been a victim of its own success, because for decades we have been the largest recipients of both [official development assistance] funding from the US for research [and] also the largest recipients of NIH funding outside of the US,” says president and CEO of the SAMRC Professor Ntobeko Ntusi.

Determining the exact amount of research funds we get from the US is challenging. This is because funding has come from several different US government entities and distributed across various health research organisations. But the bulk of US research funding in South Africa clearly came from the NIH, which is also the largest funder of global health research.

According to Ntusi, in previous years, the NIH invested, on average, US$150 million – or almost R3 billion – into health research in South Africa every year.

By comparison, the SAMRC’s current annual allocation from government is just under R2 billion, according to Ntusi. “Our baseline funding, which is what the national treasury reflects [approximately R850 million], is what flows to us from the [Department of Health],” he says, adding that they also have “huge allocations” from the Department of Science, Technology and Innovation. (Previous Spotlight reporting quoted the R850 million figure from Treasury’s budget documents, and did not take the additional funds into account.)

How is the SAMRC tracking US funding terminations

Ntusi and his colleagues have been trying to get a clearer picture of the exact extent and potential impacts of the cuts.

While some US funding given to research units in South Africa flows through the SAMRC, the bulk goes directly to research units from international research networks, larger studies, and direct grants. Keeping track of all this is not straight-forward, but Ntusi says the SAMRC has quite up to date information on all the terminations of US research awards and grants.

“I’ve been communicating almost daily with the deputy vice-chancellors for research in all the universities, and they send me almost daily updates,” says Ntusi. He says heads of research units are also keeping him informed.

According to him, of the approximately US$150 million in annual NIH funding, “about 40%…goes to investigator-led studies with South Africans either as [principal investigators] or as sub-awardees and then the other 60% [comes from] network studies that have mostly sub-awards in South Africa”.

Figures that Ntusi shared with Spotlight show that large tertiary institutions like the University of the Witwatersrand, the University of Cape Town, and the University of Stellenbosch, could in a worst case scenario lose over R200 million each, while leading research units, like the Desmond Tutu Health Foundation and the Centre for the AIDS Programme of Research in South Africa, could each lose tens of millions. The SAMRC figures indicate that while many grants have already been terminated, there are also a substantial number that have not been terminated.

Where will new money come from?

Ntusi says the SAMRC is coordinating efforts to secure new funding to address the crisis.

“We have been leading a significant fundraising effort, which…is not for the SAMRC, but for the universities who are most affected [and] also other independent research groups,” he says. “As the custodian of health research in the country, we are looking for solutions not just for the SAMRC but for the entire health research ecosystem.”

Ntusi explains that strategically it made more sense to have a coordinated fundraising approach rather than repeating what happened during COVID-19 when various groups competed against each other and approached the same funders.

“Even though the SAMRC is leading much of this effort, there’s collective input from many stakeholders around the country,” he says, noting that his team is in regular communication with the scientific community, the Department of Health, and Department of Science, Technology and Innovation.

The SAMRC is also asking the Independent Philanthropic Association of South Africa, and large international philanthropies for new funding. He says that some individuals and philanthropies have already reached out to the SAMRC to find out how they can anonymously support research endeavours affected by the cuts.

Can government provide additional funds?

Ntusi says that the SAMRC is in discussions with National Treasury about providing additional funds to support health researchers through the funding crisis.

The editors of Spotlight and GroundUp recently called on National Treasury to commit an extra R1 billion a year to the SAMRC to prevent the devastation of health research capacity in the country. They argued that much larger allocations have previously been made to bail out struggling state-owned entities.

Government has over the last decade spent R520 billion bailing out state-owned entities and other state organs.

How will funds raised by the SAMRC be allocated?

One dilemma is that it is unlikely that all the lost funding could be replaced. This means tough decisions might have to be made about which projects are supported.

Ntusi says that the SAMRC has identified four key areas in need of support.

The first is support for post-graduate students. “There’s a large number of postgraduate students…who are on these grants” and “it’s going to be catastrophic if they all lose the opportunity to complete their PhDs,” he says.

Second is supporting young researchers who may have received their first NIH grant and rely entirely on that funding for their work and income, says Ntusi. This group is “really vulnerable [to funding terminations] and we are prioritising [their] support…to ensure that we continue to support the next generation of scientific leadership coming out of this country,” he says.

A third priority is supporting large research groups that are losing multiple sources of funding. These groups need short-term help to finish ongoing projects and to stay afloat while they apply for new grants – usually needing about 9 to 12 months of support, Ntusi explains.

The fourth priority, he says, is to raise funding to ethically end clinical and interventional studies that have lost their funding, and to make sure participants are connected to appropriate healthcare. Protecting participants is an important focus of the fundraising efforts, says Ntusi, especially since many people involved in large HIV and TB studies come from underprivileged communities.

Ultimately, he says they hope to protect health research capacity in the country to enable South African health researchers to continue to play a meaningful and leading role in their respective research fields.

“If you reflect on what I consider to be one of the greatest successes of this country, it’s been this generation of high calibre scientists who lead absolutely seminal work, and we do it across the entire value chain of research,” says Ntusi. “I would like to see…South Africa [continue to] make those meaningful and leading pioneering contributions.”

Republished from Spotlight under a Creative Commons licence.

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Categories : Infection Control Respiratory DiseasesTags :

New Research Challenges Thinking on the Places Where TB is Transmitted

On By ModernMedia
Photo by Alex Haney

By Biénne Huisman

For centuries, it was believed that tuberculosis spread primarily when a vulnerable person spends hours in a poorly ventilated space with someone infectious. But new findings suggest that much TB transmission also occurs through casual contact.

Conventional thinking held that enclosed spaces such as households, prisons, and shelters, where people spent long periods of time together, were where most TB transmission took place. But new data suggest that casual contact at social settings like shopping malls, restaurants, bars, and places of worship also account for much TB transmission.

A recent study found that close contact explained only 9% of TB transmission links, while casual contact accounted for 49%. The study, called CONTEXT (Casual Contact and Migration in XDR TB), was conducted in KwaZulu-Natal.

The study’s lead author, Professor Neel Gandhi of Emory University in Atlanta, recently presented the findings at the Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco. The work has not yet been published in a peer-reviewed medical journal.

The new findings come in the context of other research (much of which was conducted in Cape Town) that suggest TB could be transmitted through breathing, and growing evidence that people with asymptomatic TB can transmit the infection.

Where transmission occurs

Gandhi tells Spotlight that TB transmission has traditionally been linked to prolonged, close contact, with previous studies showing that 9 to 30% of cases could be attributed to this type of contact. A compelling alternative argument, he says, is that the remaining 70% of transmission occurs due to casual contact in community settings – which is what their research sought to explore.

He elaborates: “For much of history, we have thought that most TB transmission occurs through close and prolonged contact, meaning that a susceptible person is spending a lot of time in a poorly ventilated area with somebody who is infectious. And so most often we think of households as places where transmission occurs; or congregate settings, places like prisons or homeless shelters.”

On defining casual contact, he says: “In our research, we wanted to understand less intense forms of contact where transmission can occur. So, we understood where people lived, but we also asked them where they spent time in a typical week. The phrase we used was: ‘where do you spend two hours or more, most weeks?’ To try to identify the places people spend substantial amounts of time; and seeing whether they crossed paths with somebody else to whom their molecular fingerprints (of their TB bacteria infection) match.”

Genotyping, and geomapping

In their study, Gandhi and his colleagues made use of both genotyping and geospatial mapping to figure out where TB transmission likely occurred.

Genotyping, explains Gandhi, is a technology developed about 30 years ago that allows us to examine the genetic code of TB bacteria, and to compare similarity between patients’ bacteria.

“TB is a bacteria that keeps its genetic code similar across many generations of replication. In layman’s terms, we call this molecular fingerprinting. If I were to transmit TB to somebody else; my TB bacteria and that person’s TB bacteria’s genetic codes would look very similar – almost identical – so we could use this fingerprinting technique by sequencing the genomes of the two TB bacteria to try to fully get a sense of what the likelihood of transmission was.”

Commenting on their geospatial methodology, he says: “When our participants told us where they live or where they spend time in the community, or where they get outpatient healthcare; our team went to those sites and captured a GPS coordinates.

“Just like we use GPS for mapping when we’re trying to get around town, we would get specific coordinates… If two people went to the same shop, they might have used different names for that shop, or let’s say they went to a shopping mall, they may have used different names for those places; but we used GPS coordinates allowing us to determine whether they were at the same place or close to one another. And we used the concept of proximity to try to understand the likelihood that they may have crossed paths.”

In the study they used the metric of “community proximity” defined as a radius of 500 metres, or less.

Gandhi illustrates the nuance of geomapping, using his university campus: “So the example I like to give is; I work in a building called the School of Public Health. Across the courtyard is the School of Nursing. If you just asked me, where do you work? I would tell you, I work in this building. If you ask the next person where they work, they may say, I work in the School of Nursing. That wouldn’t match up in terms of place name. But if we used a radius of 100 metres or 500 metres, we can determine that we work very close to one another. And there’s a cafe in yet another building that we may have eaten lunch in at the same time. TB being an airborne disease, I don’t have to sit next to that person or even to know that person; if I’m infectious, I could have transmitted to them if they were sitting and eating in the same room.”

Essentially, the researchers used genotyping, particularly molecular fingerprinting to help understand the likelihood of transmission between people who have drug resistant TB. And once individuals with similar molecular fingerprints were found, they used geomapping to see whether these patients could be connected through close contact – and if not close contact, then through casual contact.

He adds: “The most common place people told us were friends and family members’ homes. Then the next most common was places of shopping so shopping malls.”

At CROI, Gandhi responded to a question from a conference delegate around risk, saying that there appears to be a greater risk of TB transmission in social settings than previously understood.

Symptoms and disease

To Spotlight, he says more work is needed to understand why casual contact transmission is happening. “And it connects to another topic in the TB community that is gaining a lot of attention currently, which is trying to understand what the association is between symptoms and having TB disease,” says Gandhi.

He notes that the challenge for researchers moving forward is understanding the link between infectiousness and symptoms – specifically, understanding when a person becomes infectious, even if they show no symptoms.

Most TB public health interventions are still based on the assumption that people with TB will present at health facilities with classic TB symptoms such as persistent cough, night sweats, fever, weight loss, and chest pain. South Africa has however in recent years been offering TB tests to asymptomatic people thought to be at high risk of TB, as part of its targeted universal testing strategy.

“So you may have heard of this concept of what some people have called subclinical TB or asymptomatic TB.  And that is to say, if you were to test a group of people who didn’t come to a health clinic, but let’s say you were on a street corner and you tested everybody who went by for TB, we’re coming to appreciate that as many as 50% of people may not either have any symptoms or may not have symptoms that are worrisome enough for them to seek healthcare, but are actually testing positive for TB disease,” Gandhi adds.

Gandhi says this reminds him of the early days of COVID-19, when scientists weren’t sure if people only became infectious after showing symptoms.

“Eventually we learned that people were infectious probably for a few days before they developed symptoms. And in the TB world, this may be an area we need to investigate. If there’s the possibility that somebody is infectious when they have absolutely no symptoms, they would go about their regular activities; going to work, going to school, going shopping, going to religious ceremonies, going to restaurants, and they may unknowingly be infectious with TB. So this is the challenge.”

The bigger picture

Commenting on the findings, Robert Wilkinson, Honorary Professor in the Department of Medicine at the University of Cape Town and director of the Centre for Infectious Diseases Research in Africa, says: “It is interesting, and the proportion of transmission estimated to occur outside the household is a low estimate, but not incompatible with other estimates.”

He notes that the phenomenon of transmission occurring after brief casual contact is not novel though, and has been investigated in previous studies.

Asked how the findings presented by Gandhi might affect the outlook on TB interventions, Wilkinson says: “Whilst close household exposure to infectious tuberculosis should prompt clinical evaluation especially if there are symptoms, finding a close contact by conventional contact tracing approaches is far from invariable. Therefore, in high incidence environments like South Africa more attention needs to be placed on mass radiographic (X-ray) and, or microbiological screening of asymptomatic persons.”

In a recent public lecture called ‘Hunting Bosons, Finding the Bummock’, Emeritus Professor in Medicine at the University of Cape Town, Robin Wood, former CEO of the Desmond Tutu Health Foundation, states: “I think we are changing the paradigm of tuberculosis.” He notes that research now targets “hidden reservoirs of TB transmission beyond visible, symptomatic cases… [as] TB silently spreads within communities through carriers who exhibit no symptoms yet contribute to transmission.” Asked about Gandhi’s findings, Wood told Spotlight he would reserve comment until the data is submitted for further peer review and publication.

Study details

The 305 respondents in the CONTEXT study were patients with extensively drug-resistant TB or pre-extensively drug-resistant TB. They were diagnosed between 2019 and 2022 in the eThekwini, Ilembe, Umgungundlovu, and Ugu regions. The average age was 36 years, with 137 (45%) women and 216 (73%) people living with HIV.

The study was conducted in collaboration with the Durban-based Centre for the AIDS Programme of Research in South Africa (CAPRISA).

“CAPRISA played a leadership role in conceptualising the science, development of the protocol and data collection instruments, oversight of all aspects of field work, including screening and enrolling patients, obtaining informed consent from patients or their proxy’s, field and laboratory data collection, data verification and data clean-up activities for all data used in this study,” says CAPRISA’s deputy director, Professor Kogieleum Naidoo.

CONTEXT was funded through the United States National Institutes of Health (NIH), the world’s largest health research funder which has in recent weeks terminated several grants in South Africa and elsewhere. “The funding period has ended,” says Gandhi. “Now we’re analysing all of the data, so it won’t be impacted by any changes happening at NIH.”

Republished from Spotlight under a Creative Commons licence.

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Categories : HIVTags :

8 Million People Living with HIV in SA, According to Latest Estimates

On By ModernMedia
Photo by Miguel Á. Padriñán

By Marcus Low

The number of people living with HIV in South Africa has for the first time reached the eight million mark. Of these, around 6.2 million are on treatment, according to new estimates.

The number of people living with HIV in South Africa continues to rise, surpassing eight million in 2024. This is according to just-released estimates from Thembisa, the leading mathematical model of HIV and TB in South Africa. The eight million amounts to 12.8% of the population.

The continued rise is due to the fact that there are more people becoming newly infected with HIV than there are people with HIV who are dying. The increasing numbers are thus a reflection of the fact that antiretroviral medicines are keeping people alive who would otherwise have died.

There was an estimated 178 000 new HIV infections in 2023/2024 (mid-2023 to mid-2024). Over the same period, around 105 000 people with HIV passed away – 53 000 due to HIV-related causes and 52 000 for reasons not related to HIV.

The estimates of new HIV infections are slightly higher than in last year’s Thembisa publications. According to Dr Leigh Johnson, of the University of Cape Town and the key developer of the Thembisa model, this is mainly due to the model factoring in new evidence that condom usage is declining.

78% treatment coverage

Of the eight million people living with HIV, around 6.2 million, or 78%, were taking antiretroviral treatment in 2024. Around one in five people living with the virus were thus not on treatment. Treatment is recommended for everyone living with HIV.

On the UNAIDS 95-95-95 targets, also endorsed in South Africa’s National Strategic Plan for HIV, TB and STIs 2023 – 2028, the middle target, helping people start and stay on treatment, continues to be the main area of underperformance. Around 95% of people living with HIV in South Africa knew their status in 2024, around 81.5% of these were on antiretroviral treatment, and of those on treatment, around 92% had viral suppression. (Note that the 78% treatment coverage figure is the product of multiplying the performance on the first two 95 targets.)

There continues to be stark gender disparities in South Africa’s HIV epidemic. On the one hand, there are many more women living with HIV than men – 5.2 million compared to 2.6 million as of mid-2024. On the other hand, slightly more men died of HIV-related causes than women in 2023/2024 – 27 100 men compared to 24 200 women.

Worrying trends

One ongoing area of concern is that many people only start treatment once their immune systems have been severely compromised. In 2023/2024, around 54 000 adults started treatment for the first time with CD4 counts below 200 cells/mm3. A CD4 count above 500 cells/mm3 is generally considered to be healthy. CD4 cells are a type of white blood cell that is vital to the functioning of the immune system. People who start treatment with low CD4 counts tend to have worse long-term outcomes.

The latest Thembisa outputs also contain worrying findings on the extent to which people drop in and out of care. In 2023/2024, an estimated 714 000 people restarted antiretroviral treatment after previously having stopped for at least a month – of these, around 326 000 had CD4 counts below 200 cells/mm3.

Finally, on a more positive note, the latest Thembisa outputs continue to show a rise in life expectancy in South Africa. As shown in the above graph, life expectancy declined severely round the turn of the century, largely due to people dying of AIDS, but then increased over time as antiretroviral therapy started keeping people living with HIV alive. The blip in 2020 and 2021 is due to the COVID-19 pandemic.

Note: This article is based on outputs from Thembisa version 4.8 – published in late March 2025. We have quoted 2023/2024 figures since they are based on more data, and thus more reliable than the estimates for 2024/2025. We have rounded some numbers to make the text more accessible. Graphs were made using the R package ggplot2. Spotlight will soon publish an #InTheSpotlight special briefing in which we will unpack the Thembisa 4.8 outputs in more detail.

Republished from Spotlight under a Creative Commons licence.

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Categories : New Compounds and Treatments Respiratory DiseasesTags :

Excitement Builds for Long-acting TB Treatments, but Research Still at Early Stage

On By ModernMedia
Mycobacterium tuberculosis drug susceptibility test. Photo by CDC on Unsplash

By Catherine Tomlinson

Both TB treatment and TB preventive therapy involve taking lots of pills, usually for several months. Researchers are working on new long-acting formulations that might, for example, reduce an entire course of TB preventive therapy to a single injection.

The biggest HIV news of last year was that an injection containing an antiretroviral called lenacapavir provides six months of protection against HIV infection per shot. While it will be several years before the jabs become widely available, experts nevertheless hailed the development as a potential game-changer. In some countries, HIV treatment is already available as injections – containing the antiretrovirals cabotegravir and rilpivirine  – administered every two months.

Scientists working on tuberculosis (TB) are trying to replicate the successes of the HIV field and develop similarly long-acting formulations of TB medicines. The good news is that they have several exciting products under development – the bad news is that the research is still at a very early stage and the pivotal studies that will tell us if these products work are likely still years away.

But if they work, they could make a big difference to patients. That is because TB treatment and TB preventive therapy mostly still requires swallowing lots of pills over a long period of time. There is some good evidence that many people would prefer long-acting injections.

The case for long-acting TB medicines

TB preventive therapy is used to stop someone suspected of having latent TB infection from falling ill with TB. In South Africa, such preventive therapy is recommended for all close contacts of someone sick with TB. Typically, it involves taking tablets for three or six months (a one-month course has been shown to work, but is not widely available). There is research that shows that the shorter the regimen the more likely it is to be completed.

The hope is that a long-acting product might do away with swallowing tablets altogether and reduce an entire course of preventive therapy to a single injection. This is likely to be more convenient for patients as well as come with the benefit of perfect treatment completion rates.

TB preventive therapy is a simpler target for long-acting formulations than TB treatment since it typically involves only one or two drugs and treatment durations are shorter. TB treatment typically takes six or more months to complete and usually involves taking four different drugs – often four for two months and then only two for the remaining four months in what is called the continuation phase. Some of the current thinking is that the continuation phase could potentially be replaced by long-acting formulations of TB medicines. This could shorten the duration of TB treatment to just two months of taking tablets.

Not an easy nut to crack

As explained by Dr Eric Nuermberger of Johns Hopkins University, not all TB medicines available as tablets make good candidates for translation to long-acting injectable formulations. He was presenting on long-acting TB drugs at the Conference for Retroviruses and Opportunistic Infections (CROI), recently held in San Francisco.

Nuermberger outlined three key characteristics that are needed for long-acting formulations. These are low water solubility (so the drug doesn’t dissolve to quickly), low clearance in plasma (so that the body doesn’t clear the drug too quickly), and high drug potency (so that a small volume of drug can be effective for a long period of time).

One key challenge, according to Nuermberger, is that scientists do not yet have reliable biomarkers to measure the effectiveness of long-acting TB preventive therapy in phase II trials. Biomarkers, such as blood levels of certain proteins, could in theory offer scientists a faster way to assess if TB preventative therapy is working, without having to monitor clinical trial participants for long periods of time to determine treatment outcomes.

Writing in the journal Clinical Infectious Diseases, scientists working to develop long-acting TB products explained: “The inability to culture or otherwise quantify viable bacteria during latent TB infection and the lack of validated surrogate biomarkers mean that there is no opportunity to obtain initial proof of efficacy… which is usually the domain of phase 2 trials. Instead, the development of new TPT regimens requires bridging directly from preclinical studies and phase 1 trials to phase 3 trials, which are themselves long and require large numbers of participants.”

However, they added that “[t]he search for biomarkers that act as prospective signatures of risk for developing TB disease is a very active research area and an important scientific priority for the field”.

Back at CROI, Nuermberger also told participants that most products in the pipeline remain at pre-clinical stages and are still being tested in mice. He explained that differences in how depot drugs — drugs released slowly over time — work in mice and humans make it hard to apply findings from mice to humans. But modeling is being done to help bridge this gap.

‘Expanded remarkably’

Despite these challenges, Nuermberger said “the number of long-acting drug formulations in development [for TB] has really expanded remarkably in the last few years, which is a very promising development”.

The product that is furthest along in the development pipeline, but still at a very early stage of research, is a long-acting form of bedaquiline. This drug is currently used for the treatment of drug-resistant forms of TB and falls in a class of antibiotics known as diarylquinolines.

The Belgian pharmaceutical company Janssen is currently running a phase I trial of long-acting injectable bedaquiline in Austria. Phase I trials are conducted in a small group of healthy individuals to assess the safety and tolerability of an experimental medicine. In the phase 1 bedaquiline trial, researchers are investigating the safety and tolerability of different doses of long-acting injectable bedaquiline.

Several other long-acting TB medicines are being investigated in preclinical research, including long-acting versions of the TB medicines rifabutin and rifapentine, as well as the second generation diarylquinolines, TBJ-876 and TBA-587, which are under development by the TB Alliance. The second generation diarylquinolines are being tested on their own and in combination with pretomanid and telacebec.

In addition, the University of Liverpool, Johns Hopkins University, University of Southern Denmark, University of North Carolina and the US pharmaceutical company Inflamamasome Therapeutics, are all involved in pre-clinical research on long-acting formulations. These efforts are supported financially by Unitaid, the US National Institutes of Health, and the Gates Foundation.

The treatments being developed include aqueous nanoparticle suspensions, in-situ forming implants, and rod implants. Aqueous nanoparticle suspensions are drugs turned into tiny particles and delivered in a water-based solution via injection. In-situ forming implants are injected as a liquid that then solidifies into an implant under the skin. Rod implants are small, rod-shaped devices inserted under the skin with a needle-like tool after numbing the area with a local anaesthetic.

What users prefer

At CROI, delegates also learned about patient and provider preferences for long-acting TB treatment.

Dr Marcia Vermeulen from the University of Cape Town presented the results of a survey involving over 400 patients in South Africa and India, as well as 94 healthcare providers.

Seventy-five percent of healthcare workers said they would prescribe a long-acting injectable product rather than pills for tuberculosis preventative therapy if it was priced the same or lower. Similarly, 75% of patients said they would try an injectable product for TB prevention if it became available.

“As a TB survivor, I am excited about long-acting TB treatment as it doesn’t require frequent facility visits, saving a person’s time and money, and can thereby increase adherence and improve treatment outcomes,” TB Proof’s Phumeza Tisile told Spotlight.

She added that communities should be at the heart of rollout plans because they understand the needs of people affected by TB and know how to communicate effectively to encourage involvement and adoption.

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

Republished from Spotlight under a Creative Commons licence.

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Categories : Expert Opinion Healthcare Politics and RegulationsTags :

What does it Mean for Health? SAMRC Experts Weigh in on Budget 2025

On By ModernMedia
Finance Minister Enoch Godongwana holding a copy of the 2025 Budget Speech. (Photo: Parliament of RSA via X)

By Charles Parry, Funeka Bango, Tamara Kredo, Wanga Zembe, Michelle Galloway, Renee Street and Caradee Wright

While the 2025 national budget boosts health spending, researchers from the South African Medical Research Council stress the need for strong accountability measures. They also raise concerns about rising VAT and omissions related to US funding cuts and climate change.

The 2025 budget speech by Finance Minister Enoch Godongwana saw a welcome boost to the health budget with an increased allocation from R277 billion in 2024/2025 to R329 billion in 2027/2028. This signals a government that is responding to the dire health needs of the public sector, that serves more than 80% of the South African population.

As researchers at the South African Medical Research Council (SAMRC), we listened with interest and share our reflections on some of the critical areas of spend relevant for health and wellbeing.

We note the increase in investment in human resources for health and allocations for early childhood development and social grants. At the same time, we also raise concern about increasing VAT, with knock-on effects for the most vulnerable in our country. There were also worrying omissions in the speech, such as addressing the impact of the United States federal-funding freeze on healthcare services nationally, and a noticeable absence of comment on government’s climate-change plans.

Health and the link with social development: Recognising the importance of early childhood development

Education and specifically early childhood development (ECD) is known to have critical impacts on children’s health and wellbeing, with longstanding effects into youth and adulthood. In South Africa, eight million children go hungry every day, and more than a third of children are reported to live in households below the food poverty line, that is below the income level to meet basic food requirements, not even covering other basic essentials such as clothes.

While the increase in the number of registered ECDs is laudable, many more ECD centres in low-income areas remain unregistered, which means they do not get support from the government in terms of subsidies and oversight.

Social grants

The increase in social grants is welcomed. However, the marginal increase of the Child Support Grant (CSG) by only R30, from R530 to R560, is too little to impact on the high levels of child hunger and malnutrition. The release of the Child Poverty Review in 2023, which highlighted the eight million children going hungry every day, including CSG recipients, proposed the immediate increase of the CSG to at least the Food Poverty Line (R796 in 2024).

Social relief of distress still too small

The Social Relief of Distress (SRD) Grant is an important source of income for low-income, working-age, unemployed adults. Its continuance in 2025 is welcomed. However, it remains too small at R370 per person per month, and the stringent means-test criteria which disrupt continuous receipt from month-to-month, makes it an unreliable, unpredictable source of income for low-income individuals.

Strengthening the healthcare workforce

The Minister stated that “R28.9 billion is added to the health budget, mainly to keep about 9 300 healthcare workers in our hospitals and clinics”. It will also be used to employ 800 post-community service doctors, and to ensure that our pharmacies do not run out of medicines. The speech highlighted the necessary commitment to strengthening the healthcare system, specifically human resources for health.

Considering the pressures on resources, primarily due to the escalating disease burden and challenges within the health workforce, the proposed budget increase from R179 billion to R194 billion – an increase of 8.2% – to maintain the current workforce and employ additional healthcare workers signifies a positive step forward that will aid in addressing staff shortages.

However, this seems to fall short of what is needed to ensure all medical graduates are placed, and government’s own 2030 Human Resources for Health Strategy.

VAT vs. health taxes

Despite the gains in health spending, the proposed increase in VAT raises substantial concerns to partially negate the potential benefits to the health sector. As the World Bank reports that approximately 60% of people living in South Africa live below the poverty line, increases to VAT will likely drive poverty levels higher.

A focus on other forms of taxation may be better, more evidence-based, and less likely to disproportionately affect those at the highest levels of poverty.

On the issue of alcohol taxes, often mischaracterised as “sin taxes” rather than “health taxes”, the Minister has proposed excise duties of 6.75% on most products for 2025/26. This is 2% above consumer inflation, which stands at 4.75%.

Raising alcohol prices through higher excise taxes is globally recognised as an effective way to address alcohol-related harms. National Treasury is to be commended for adjusting alcohol excise tax rates above CPI in the 2025/26 Budget. This is a move in the right direction, but it does not address the current anomalies in tax rates across different products. This failure to address shortcomings in the excise tax regime is expected, given the release of a discussion document on alcohol excise taxes in December 2024 with a February 2025 response date. The earliest we can expect substantial changes in excise tax rates is in February 2026.

From a public-health perspective, it makes sense to link alcohol excise taxes to the absolute alcohol content of the product to standardise across products. Ethanol is ethanol. The current differential in excise tax rates on different alcohol products is indefensible. Specifically, it makes no sense to tax wine and beer so much less than spirits in terms of absolute alcohol content. Wine, especially bag-in-box wine, is the cheapest product on the market in South Africa, and its affordability increases consumption, leading to more societal harm.

Beer is the most consumed product in the country and is increasingly sold in larger, non-resealable containers. A 2015 SAMRC study in Gauteng found the highest level of heavy episodic drinking with beer products, largely due to their affordability, especially in larger, non-resealable containers. Heavy episodic drinking is a major public-health concern in South Africa, with 43.0% of current drinkers engaging in heavy episodic drinking at least monthly, 50.9% of male and 30.3% of female drinkers. Increasing the excise tax on beer is a powerful tool that the state can use to reduce the level of such behaviour.

Additionally, it makes sense to have lower taxes on alcohol products with lower alcohol content, as this could shift consumption to less harmful products. The current excise tax regimen does not account for this within a single product type like beer or wine, as all products are taxed at the same rate regardless of their alcohol content.

During the COVID-19 pandemic, we saw the benefits of decreased access to alcohol: fewer injuries, fewer unnatural deaths, and communities less disrupted by patrons visiting liquor outlets. While no one advocates for total liquor sales bans, increasing excise taxes on wine and beer would decrease alcohol consumption and reduce harms on drinkers, on others around them, and on society more broadly.

Acute risk to lives with knock on effects due to US federal funding cuts

We believe the South African government has a responsibility to step into the gap left by the sudden US federal funding freeze on HIV and TB services. The US President’s Emergency Plan for AIDS Relief (PEPFAR) funds 17% of HIV and TB services in South Africa and covers salaries for thousands of health workers, including the vital services of community health workers.

The implications for people living with HIV and TB and affected by the externally funded services will be devastating. It will also have ripple effects on the health system as we see inevitable increases in demand for health services to address advancing illness, effects on families caring for ill relatives or losing income.

This area needs to be addressed and clear communication from the National Department of Health is urgently awaited. The US funding cuts clearly impact on essential research funding available to institutions like the SAMRC and no indication has been given in the budget of any plans to augment or replace such funding.

National Health Insurance for South Africa’s public sector

The Minister addressed budget allocations for NHI implementation, specifically, the mid-term indirect and direct conditional grants for NHI were R8.5 billion and R1.4 billion respectively. Although these amounts in themselves are minor compared to other health-budget allocations, allocations for infrastructure (R37.4 billion over the mid-term economic framework period) and additionally allocations for digital patient health information systems, chronic medicine dispensing and distribution systems, and medicine stock surveillance systems are vital for healthcare efficiency and improved outcomes.

Least said not soonest mended: climate change – ‘no comment’?

From a climate-crisis perspective, although the budget speech did not explicitly mention climate change or its related health challenges, there seems to be positive steps being taken to address these issues. Initiatives such as clean energy projects and efforts to improve water management have the potential to benefit all sectors of society, while helping to mitigate the health risks associated with climate change.

Promising spend on health, but who will measure the impact?

Ultimately, increasing health spend is a promising step to increase access to quality health services for South Africa’s population. However, this is not enough, government must seize the opportunity to translate the budget increase into improved health outcomes. The effectiveness of the additional funds must be maximised through efficiency, transparency, and sound governance. The government can reinforce the integrity of public-health services by aligning these increases with robust accountability measures.

Government-academic partnerships represent an opportunity to share knowledge, technical skills and resources to support evidence-informed decision-making for national health decision-making and strengthen monitoring and evaluation mechanisms. There are many examples of this working well, and we trust that the SAMRC, along with the network of higher education institutions are well placed to provide the necessary support.

*Parry, Bango, Kredo, Zembe, Galloway, Street and Wright are researchers with the SAMRC.

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 : HIVTags :

SA Unveils Ambitious New HIV Campaign amid Aid Crisis

On By ModernMedia
Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/syringe-and-pills-on-blue-background-3936368/

By Ufrieda Ho

Amid major disruptions caused by aid cuts from the United States government, the health department aims to enrol a record number – an additional 1.1 million – of people living with HIV on life-saving antiretroviral medicine this year. Experts tell Spotlight it can’t be business as usual if this ambitious programme is to have a chance of succeeding.

Government’s new “Close the Gap” campaign launched at the end of February has set a bold target of putting an additional 1.1 million people living with HIV on antiretroviral treatment by the end of 2025.

Around 7.8 million people are living with HIV in the country and of these, 5.9 million are on treatment, according to the National Department of Health. The target is therefore to have a total of seven million people on treatment by the end of the year. Specific targets have also been set for each of the nine provinces.

The initiative is aimed at meeting the UNAIDS 95–95–95 HIV testing, treatment and viral suppression targets that have been endorsed in South Africa’s National Strategic Plan for HIV, TB, and STIs 2023 – 2028. The targets are that by 2030, 95% of people living with HIV should know their HIV status, 95% of people who know their status should be on treatment, and 95% of people on treatment should be virally suppressed (meaning there is so little HIV in their bodily fluids that they are non-infectious).

Currently, South Africa stands at 96–79–94 against these targets, according to the South African National Aids Council (SANAC). This indicates that the biggest gap in the country’s HIV response lies with those who have tested positive but are not on treatment – the second 95 target.

But adding 1.1 million people to South Africa’s HIV treatment programme in just ten months would be unprecedented. The highest number of people who started antiretroviral treatment in a year was the roughly 730 000 in 2011. In each of the last five years, the number has been under 300 000, according to figures from Thembisa, the leading mathematical model of HIV in South Africa. According to our calculations, if South Africa successfully adds 1.1 million people to the HIV treatment programme by the end of 2025, the score on the second target would rise to just above 90%.

The record for the most people starting antiretroviral treatment in a single year was approximately 730 000 in 2011. (Graph by Spotlight, based on Tembisa data.)

The ambitious new campaign launches at a moment of crisis in South Africa’s HIV response. Abrupt funding cuts from the United States government – the PEPFAR funding – has meant that the work of several service-delivery NGOs have ground to a halt in recent weeks.

These NGOs played an important role in getting people tested and in helping find people and supporting them to start and restart treatment. The focus of many of these NGOs was on people in marginalised but high-risk groups, including sex workers, people who use drugs and those in the LGBTQI community. As yet, government has not presented a clear plan for how these specialised services might continue.

“We will need bridging finance for many of these NGOs to contain and preserve the essential work that they were doing till we can confer these roles and responsibilities to others,” says Professor Francois Venter, of the Ezintsha Research Centre at the University of the Witwatersrand.

He says good investment in targeted funding for NGOs is a necessary buffer to minimise “risks to the entire South African HIV programme” and the looming consequences of rising numbers of new HIV cases, more hospitalisations, and inevitably deaths.

Disengaging from care

South Africa’s underperformance on the second 95 target is partly due to people stopping their treatment. The reasons for such disengagement from HIV care can be complex. Research has shown it is linked to factors like frequent relocations, which means people have to restart treatment at different clinics over and over. They also have to navigate an inflexible healthcare system. A systematic review identified factors including mental health challenges, lack of family or social support, long waiting times at clinics, work commitments, and transportation costs.

Venter adds that while people are disengaged from care, they are likely transmitting the virus. The addition of new infections for an already pressured HIV response contributes to South Africa’s sluggish creep forward in meeting the UNAIDS targets.

The health department has not been strong on locating people who have been “lost” to care, says Venter. This role was largely carried out by PEPFAR-supported NGOs that are now unable to continue their work due to the withdrawal of crucial US foreign aid.

Inexpensive interventions

Other experts working in the HIV sector, say the success of the Close the Gap campaign will come down to scrapping programmes and approaches that have not yielded success, using resources more efficiently, strategic investment, and introducing creative interventions to meet the service delivery demands of HIV patients.

Key among these interventions, is to improve levels of professionalism in clinics so patients can trust the clinics enough to restart treatment.

Professor Graeme Meintjes of the Department of Medicine at the University of Cape Town says issues like improving staff attitudes and updating public messaging and communications are inexpensive interventions that can boost “welcome back” programmes.

“The Close the Gap campaign must utilise media platforms and social media platforms to send out a clear message, so people know the risks of disengagement and the importance of returning to care. The longer someone interrupts their treatment and the more times this happens, the more they are at risk of opportunistic infections, severe complications, getting very sick and needing costly hospitalisations,” he says.

Clinics need to provide friendly, professional services that encourage people to return to and stay on treatment, Meintjes says, and services need to be flexible. These could include more external medicine pick-up points, scripts filled for longer periods, later clinic operating hours, and mobile clinic services.

“We need to make services as flexible as possible. People can’t be scolded for missing an appointment – life happens. Putting these interventions in place are not particularly costly, in fact it is good clinical practice and make sense in terms of health economics by avoiding hospitalisations that result from prolonged treatment interruptions,” he says.

The Close the Gap campaign, Meintjes adds, should reassure people that HIV treatment has advanced substantially over the decades. The drugs work well and now have far fewer side effects, with less risk of developing resistance. More patients are stable on the treatment for longer and most adults manage their single tablet once-a-day regime easily.

Insights from our experiences

Professor Linda-Gail Bekker, Chief Executive Officer at the Desmond Tutu Health Foundation, says to get closer to the target of 1.1 million people on treatment by year-end will mean using resources better.

“Additional funding is always welcome, so are new campaigns that catalyse and energise. But we also need to stop doing the things we know don’t have good returns. For instance, testing populations of people who have been tested multiple times and aren’t showing evidence of new infections occurring in those populations,” she says.

There is also a need for better data collection and more strategic use of data, Bekker says. Additionally, she suggests a status-neutral approach, meaning that if someone tests positive, they are referred for treatment, while those who test negative are directed to effective prevention programmes, including access to pre-exposure prophylaxis (PrEP) for people at high risk of exposure through sex or injection drug use.

But Bekker adds: “We need to be absolutely clear; these people aren’t going to come to us in our health facilities, or we would have found them already. We have to do the work that many of the PEPFAR-funded NGOs were doing and that is going to the last mile to find the last patient and to bring them to care.”

She says the impact of the PEPFAR funding cuts can therefore not be downplayed. “The job is going to get harder with fewer resources that were specifically directed at solving this problem.”

Venter names another approach that has not worked. This, he says, is the persistence of treating HIV within an integrated health system. Overburdened clinics have simply not coped, he adds, with being able to fulfil the ideal of a “one-stop-shop” model of healthcare.

Citing an example, he says: “Someone might come into a clinic with a stomach ache and be vomiting, they might be treated for that but there’s no investigation or follow-up to find out if it might be HIV-related, for instance. And once that person is out of the door, they’re gone.”

Campaign specifics still lacking

The Department of Health did not answer Spotlight’s questions about funding for the Close the Gap campaign; what specific projects in the campaign will look like; or how clinics and clinic staff will be equipped or supported in order to find the 1.1 million people. There is also scant details of the specifics of the campaign online.

Speaking to the public broadcaster after the 25 February campaign launch, Health Minister Dr Aaron Motsoaledi said South Africa is still seeing 150 000 new infections every year. He said they will reach their 1.1 million target through a province-by-province approach. He used the Eastern Cape as an example.

“When you look at the 1.1 million, it can be scary – it’s quite big. But if you go to the provinces – the Eastern Cape needs to look for 140 000 people. Then you come to their seven districts, that number becomes much less. So, one clinic could be looking for just three people,” he said.

Nelson Dlamini, SANAC’s communications manager, says the focus will be to bring into care 650 000 men, as men are known to have poor health-seeking habits. Added to this will be a focus on adolescents and children who are living with HIV.

He says funding for the Close the Gap campaign will not be shouldered by the health department alone.

“This is a multisectoral campaign. Other departments have a role to play, these include social development, basic education, higher education and training, etc, and civil society themselves,” Dlamini says.

The province-by-province approach to reach the target of finding 1.1 million additional people is guided by new data sources.

“Last year, SANAC launched the SANAC Situation Room, a data hub which pulls data from multiple sources in order for us to have the most accurate picture on the status of the epidemic,” says Dlamini.

These include the Thembisa and Naomi model outputs and data from the District Health Information System and Human Sciences Research Council, he says adding that SANAC is working to secure data sharing agreements with other sectors too.

Dlamini however says the health department, rather than SANAC, will provide progress reports on the 10-month project.

Republished from Spotlight under a Creative Commons licence.

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In-depth | Will the Latest Private Health Reforms Bring Down Prices?

On By ModernMedia
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The government took its first steps towards the implementation of the recommendation of Health Market Inquiry into the private healthcare sector.

By Chris Bateman

Medical aid schemes will be given collective power to negotiate prices, according to draft regulations published last week. While some see the move as an important step toward reining in private healthcare prices, others argue that they do not go far enough and are legally unsound. We spoke to several leading experts about the proposed reforms.

Complaints about the high cost of private healthcare services in South Africa are nothing new. For the last two decades, above inflation increases to medical aid scheme premiums have been the norm. Added to this, many of the 16 or so percent of the population who are members of a scheme will have been asked to pay unexpected out-of-pocket co-payments at some point.

To understand why all this is happening, the Competition Commission launched a Health Market Inquiry (HMI) in 2014. The final HMI report, published in 2019, found that government had failed in its duty to regulate the private health sector, which it described as “neither efficient [nor] competitive”.

This failure in regulation has resulted in a private healthcare market that is “highly concentrated”, “characterised by high and rising costs of healthcare and medical scheme cover, and significant over utilisation without stakeholders being able to demonstrate associated improvements in health outcomes”, Justice Sandile Ngcobo, chairperson of the HMI panel, said at the time.

A key regulatory failure identified by the HMI  was the absence of any effective mechanisms to keep prices under control. Medical aid schemes would set a price that they would cover – but there is nothing stopping healthcare providers from charging much higher prices. This is particularly a problem for prescribed minimum benefits (PMBs) – a set of healthcare services that schemes have to cover in full.

The HMI recommended the establishment of a supply side regulatory authority (SSRA) that would be independent from both government and the private sector. Among others, the SSRA would set maximum tariffs for PMBs as well as reference tariffs for all other health services.

In September 2020, around a year after the HMI report was released, the Competition Commission published a notice that seemed to set the ball rolling on establishing a new tariff negotiating framework along the lines of the HMI recommendation. Their proposed multilateral negotiating forum would have been governed by the Council for Medical Schemes until the SSRA could be established.  But things then largely went silent, until earlier this month.

A new tariff-setting framework

On 14 February 2025, draft regulations published by the Minister of Trade Industry and Competition, Parks Tau, set out a new tariff determination framework for private healthcare in South Africa. At its core are two structures. The Tariffs Governing Body (TGB), consisting mainly of experts responsible for providing oversight in the tariff determination process, and the Multilateral Negotiating Forum (MLNF) made up of multiple stakeholders “which shall serve as the primary forum for collectively determining the maximum tariffs for prescribed and non-prescribed minimum benefits for healthcare services”.

In short, the work of negotiating and determining tariffs will be done by the MLNF, with the TGB providing some oversight and support. The TGB is also empowered to make a tariff determination when the MLNF fails to reach agreement.

The National Department of Health will have substantial control over both structures. Members of the MLNF will be appointed by the Director General of Health, and will include representatives of government, associations representing healthcare practitioners, healthcare funders, civil society, patient and consumer rights organisations, and any other regulatory body within the healthcare sector. The TGB will be located in the National Department of Health and will be chaired by an official of the department.

The regulations came in the form of a draft interim “block exemption” from certain provisions in the Competition Act. Such an exemption is required in order to enable the tariff governing body and the multilateral negotiating forum to function legally. The stated purpose of the exemption is to “contribute to the affordability of quality healthcare services…reduce costs and prevent the overutilization of healthcare services”.

In addition to the “collective determination of healthcare services tariffs”, the exemption also provides for “the collective determination of standardised diagnosis, procedure, medical device and treatment codes”, and “the collective determination of quality measurements/metrics, medicines formularies and treatment protocols/guidelines with the purpose of contributing to affordability of quality healthcare services across both PMBs and non-PMBs, contributing to reducing costs and contributing to the prevention of overutilization of healthcare services”.

The exemption doesn’t apply to everyone in the health sector. While healthcare providers like GPs and specialists are included, hospitals are not included.

Not an independent entity

While generally in favour of implementing the HMI recommendations, several experts Spotlight consulted are critical of how the government is going about it.

One line of criticism has been that the new framework is not sufficiently independent from the health department, as recommended in the HMI report.

Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand (Wits), said the regulations deviate from the requirement for independence of any price regulator from political interference – which he points out is expressly addressed by the HMI.

In a media conference on Monday, Health Minister Dr Aaron Motsoaledi cited financial constraints for failing to set up an independent regulatory body. He also said that the department had a “mandate to manage healthcare systems”.

“We’re still looking at various options on an independent regulator, but National Treasury has severe constraints,” he said.

The exemption is for a period of three years and has been described as an interim measure.

Piecemeal implementation?

Another line of criticism is that only some HMI recommendations are being implemented, whereas the HMI stressed the need for an “inter-related” approach. While the tariff-determinations may bring down prices, it will not prevent doctors from, for example, sending people for medically unnecessary scans (a form of overutilisation).

Sharon Fonn, a professor in the School of Public Health at Wits and who was part of the HMI panel, said implementing aspects of the HMI piecemeal will neither foster competition nor protect the consumer.

“Controlling prices achieves little in the absence of the recommended holistic framework, which addresses the incentives of schemes to contract on cost, quality and demand,” she said.

Costs are influenced by both price and demand. The HMI did extensive work to show that supplier-induced demand was a problem – clearly indicating that price controls would achieve nothing in the absence of broader interventions, said Van den Heever.

“You’ll be hard pressed to find tariffs rising much faster than CPI (Consumer Price Index),” said Van den Heever. “Costs rise because of claims volumes, not the tariffs. This is because the frequency of patient consultations or in-patient days can rise in response to a fixing of prices. Providers are in a position to influence this demand. Annually you could have a 3% actual cost increase, with only a third of the increase (one percentage point) due to original price (tariff) changes. This is fully addressed in the HMI,” he added.

In response to criticism over the piecemeal implementation of HMI recommendations, Motsoaledi stressed that the HMI conceded that its recommendations would be implemented in phases.

Questions of scope

Elsabe Klink, an independent healthcare legal consultant and former advisor to the South African Medical Association, said government is mixing up the coding, protocols and Health Technology Assessments (HTA) which, on the HMI recommendations, are not up for negotiation in the MNLF.

“The HMI recommended that those functions be separate. How on earth can people negotiate on how a diabetic patient can be treated. That is a scientific question,” she said.

Klink said the HTA seems to be a veiled attempt at price control, directly for healthcare professionals and indirectly, to bar from the market devices and medications that did not make it onto the protocols or formularies.

“It [the draft regulations] purports to implement Health Market Inquiry recommendations but seems to stray into issues that are integral to NHI implementation as well, notably the HTA Committee,” said Dr Andy Gray, pharmaceutical sciences expert at the University of KwaZulu-Natal and Co-Director of the WHO Collaborating Centre on Pharmaceutical Policy and Evidence Based Practice.

Justifying the HTA measures, Motsoaledi said it was to prevent “the medical arms race” where healthcare practitioners prioritised patient volumes to enable them to beat their opponents in offering the latest technology. “This behaviour ruled by a medical arms race must end,” he said. He did not specifically explain why HTA was included in the exemption and not addressed through other regulations.

Questions of legality

Questions have also been raised over the legality of the regulations and whether or not they’d be vulnerable to litigation.

Van den Heever described the new regulations as “quite strange and extremely untidy, exposing the entire enterprise to legal challenge from the outset”. He said that the exemption bypasses normal legislative processes, that require evidence-based motivations and wide consultation.

He said the exemption went beyond competition concerns by establishing new governance structures that resembled a regulatory framework rather than a competition-related exemption.

“Furthermore, the structures and framework apply to a different minister (Health) – who has the legal authority to establish such a framework – not the Minister of Trade Industry and Competition. The Competition Act provides for exemptions, but only to facilitate competition-related objectives,” he said.

Dr Rajesh Patel, the Head of the Health System Strengthening Department at the Board of Healthcare Funders, had similar concerns. He said he finds it strange that “you need the Department of Trade Industry and Competition to tell the Department of Health to do their work”.

Could providers opt out?

Another contentious, and not entirely clear, aspect of the new framework is whether healthcare providers will be able to charge higher prices than those agreed through the MLNF.

“Perhaps one of the most problematic elements is that to protect patients, there needs to be some system to prevent opting out. It is likely that providers will opt out of this system and pass on additional costs to patients,” warned Fonn.

But, when asked about healthcare providers potentially opting out, Motsoaledi said that if that happened, “we’d be back to square one where everybody can charge whatever they want. I don’t think the HMI wanted that.” He didn’t specifically clarify how the current reforms would prevent healthcare professionals from opting out.

According to the draft regulations, the tariffs determined by the MLNF are “binding on all parties to the agreement”. It does however leave the door open for bilateral negotiations outside of the MLNF, but “only for the purpose of concluding an agreement on reductions, but not increases, on the tariffs for PMBs and non-PMBs as determined by the MLNF process”. There appears to be nothing in the regulations that would prevent healthcare providers from opting out altogether and charging what they like – although it is unclear to what extent, if at all, schemes would reimburse in such instances.

Concerns over timing

On timing, there are both concerns over how long the process has taken so far, and how long it might take going forward. This month’s draft regulations were published roughly five and a half years after the publication of the HMI report. For most of this period, Motsoaledi was not health minister.

Motsoaledi blamed the COVID-19 pandemic and the national elections that followed shortly afterward for the delay.

Health Minister Dr Aaron Motsoaledi. (Photo: Kopano Tlape/GCIS)

Patel expressed serious reservations about the ability of the health department to implement the block exemption process. “If their history is anything to go by, we will see similar delays and consequently, rising healthcare costs,” he said.

Patel said that the quickest solution to render private healthcare more affordable would be if the Competition Commission granted exemptions to allow medical schemes to collectively negotiate tariffs with willing healthcare providers. The health department, he said, need not be involved at all.

“We have serious reservations about the Department of Trade, Industry and Competition putting the power in the Department of Health’s hands to manage the block exemption process. They have actively kept private healthcare expensive and inaccessible to justify the implementation of the NHI,” he claimed.

Spotlight sent written questions to the Department of Health last week and during Monday’s media conference. Though some of our questions were addressed in the media conference, others had not been responded to by the time of publication.

– Additional reporting by Marcus Low.

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ANC and its Ministers Reject Reports of NHI ‘Concessions’

On By ModernMedia
Photo by Hush Naidoo Jade Photography on Unsplash

By Chris Bateman

Recent media reports over the future of NHI have been contradictory and hard to make sense of. Spotlight chased up those in a position to know where things stand – it seems the ANC has not in fact made any major concessions on NHI. There is however agreement that medical schemes won’t be phased out in the next few years, something that likely wouldn’t have happened in any case given the poor state of the economy and the long timeline for NHI implementation. 

The ANC is holding firm on the NHI Act with Health Minister Dr Aaron Motsoaledi and the National Health Department “unaware of any compromise deals”, and the President’s office saying engagement with Business Unity SA (BUSA) is “ongoing”.

In spite of recent media reports to the contrary, neither President Cyril Ramaphosa nor Motsoaledi have conceded to any BUSA proposals on amending sections of the NHI Act. BUSA is the country’s apex business association and represents the banking, mining, and retail sectors, including the Health Funders Association, the Hospital Association of South Africa, and the Innovative Pharmaceuticals Association of South Africa.

BUSA, and several other critics of the Act, have argued that provisions should be removed that prohibit medical schemes from covering any health services covered by the NHI fund. The NHI Act has not yet been promulgated. If promulgated in its current form, the role of medical schemes will be dramatically reduced.

The DA’s spokesperson on health, Michele Clarke, told Spotlight that at the establishment of the recent GNU-convened Medium Term Development Plan (MTDP), agreement was reached that the health department would “not de-establish medical aids during the current government’s term of office”.

Spotlight understands that this amounts to a commitment not to promulgate the relevant sections of the Act in the next few years – it does not amount to a commitment to remove those sections from the act.

This is a pyrrhic victory, given that the implementation of NHI was always going to be a long-term project and that even in the most pro-NHI scenarios, the effective phasing out of medical schemes in the next few years was highly unlikely. There are also four legal challenges being brought on procedural and constitutional grounds that may further delay things.

Mist of confusion

Last week’s mist of confusion lifted when both the Presidency and Dr Stavros Nicolaou, speaking to Spotlight on behalf of BUSA, said no concessions have been made on NHI. Motsoaledi’s office also flatly denied reports that there had been any ANC or GNU compromise to remove parts of the NHI legislation that would render medical aids almost obsolete. The Spokesperson for the National Department of Health, Foster Mohale, added that he was unaware of any MTDP agreement on medical aids.

Vincent Magwenya, a spokesperson for the president, told Spotlight he was “unaware of any process leading to the amendment of the NHI Act”, claiming that Maropene Ramokgopa, Minister in the Presidency responsible for Planning, Monitoring and Evaluation, was misquoted last week.

She was quoted in news reports as saying the ANC and the DA had reached an “unofficial understanding on the NHI” following an ANC compromise to remove parts of the NHI legislation that would collapse medical aids. “Ms Ramokgopa tells me she was misreported,” said Magwenya.

Chris Laubscher, the DA’s communications head, told Spotlight: “There was never confirmation by [DA leader who is also Minister of Agriculture] John Steenhuisen that the NHI in its entirety had been excluded from the government’s Medium Term Development Plan.”

The new MTDP has not yet been made public.

Charity Ophelia McCord, the spokesperson for Steenhuisen, said the MTDP had yet to be completed and passed, but was on the Cabinet agenda for Wednesday, February 12. Spotlight was not able to verify if this was discussed.

Meanwhile, Mohale said both the health department and the minister were unaware of any compromise deal, “thus the implementation of the NHI Act continues as per the plans”.

Cannot be changed over night

If at some point the NHI Act is to be amended, the process is likely to take several years, according to Professor Olive Shisana, Social Policy Special Advisor to Ramaphosa on the NHI and health systems strengthening.

“Any process for changing an enacted law normally goes through Parliament, including an amendment from the executive,” Shisana explained. “There would first have to be consultation with the public before it even got to Parliament. Then, when it gets to Parliament there’s more consultation, this time in each of the provincial legislatures, after which it goes to the Portfolio Committee on Health which also takes written submissions. The committee then decides whether to submit it to the National Assembly. If the National Assembly passes it, it goes to the National Council of Provinces which considers each province’s input. Government took five years to get this NHI Act in place, so you can imagine it might take about as long to get parts of it excised or reversed. That’s the normal route it would have to take, I’m afraid.”

However, both the DA and BUSA are adamant that the Act needs to be changed.

Clarke said the DA remained of the view that “multiple parts of the [Act] remain problematic and dangerous for the future of healthcare in South Africa”.

She added: “The DA wants the model underpinning the NHI to be completely reworked and multiple problematic clauses amended by Parliament to ensure that the healthcare model is protected and strengthened.”

BUSA met with Ramaphosa in September last year and tabled a proposal which included striking Section 33 – which effectively collapses private medical aids as they now exist, creating a single national fund – from the NHI Act. It also calls for the implementation of mandatory health insurance which it is argued will take pressure off the public health system and bolster existing medical aids. The president has since passed it on to Motsoaledi’s office.

Neither BUSA nor the responding government parties have given any indication of when they might next meet or pronounce on the proposal.

Rejection of NHI

Meanwhile, the United Healthcare Access Coalition (UHAC), a grouping claiming to represent 80% of all private healthcare stakeholders, lodged a detailed alternative proposal with the president’s office. This entirely rejects the NHI and focuses on rehabilitating the healthcare system based on a synthesis of far-reaching recommendations which various commissions and experts have made over several decades, including the Taylor Commission and the more recent Health Market Inquiry (HMI).

In January this year, Motsoaledi promised to pronounce on the implementation of the HMI recommendations from 2019 “within weeks”. As reported by Business Day, there indeed seems to now finally be some movement on the HMI recommendations with Minister of Trade Industry and Competition Parks Tau having gazetted an exemption that newly opens the door for tariff setting in the private health sector – a move that may help rein in runaway healthcare costs.

UHAC spokesperson Dr Aslam Dasoo described their report as “everything that the NHI is not”.

“Our health pathway requires easy legislative changes and is within current fiscal constraints. We can start the process immediately. It requires a change in governance structure of the provincial health systems where politicians relinquish all direct authority over health care institutions and instead focus on strategic policy,” he previously told Spotlight.

In an online briefing launching the UHAC on Wednesday, February 12, Dasoo warned all parties in the GNU to “consider their options” as they would be “held jointly responsible” should the NHI be implemented to the detriment of South Africa.

Another UHAC executive member and CEO of the SA Private Practitioners Forum, Dr Simon Strachan, said the focus of their universal healthcare plan was on providing equitable, implementable, and sustainable healthcare.

“We need to ensure that those who can look after themselves, do (financially), while subsidising those who cannot afford to. It’s one hundred percent dependent on improving health service delivery within the public sector and creating a competitive market for people to decide where and how they access healthcare,” he said.

The UHAC coalition includes NGO’s, patient advocacy groups, the SA Medical Association, the South African Private Practitioners Forum, and the Progressive Healthcare Forum.

Asked what UHAC’s “Plan B” was if they “hit a brick wall” on their detailed proposals, Dasoo said the GNU was obliged to respond to such a widely representative proposal “otherwise they’re not fit to govern”.

Referring to the ANC, he said the party “neglected the two major healthcare systems, allowing real degradation of the public sector and an unregulated private sector with no market growth, resulting in prices going up”. He added: “If there’s any brick wall, it’s the one they’ve built.”

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No Clear Government Plan Yet to Confront US Aid Cuts

On By ModernMedia
Photo by Reynaldo #brigworkz Brigantty

By Ufrieda Ho

South Africa’s National Department of Health is still to outline a clear contingency plan as a United States (US) funding freeze puts lives at risk, spells job losses, and presents threats to keeping HIV and TB under control.

The ripple effects of US President Donald Trump’s 90-day freeze of funding on foreign aid programmes have hit South Africa hard. The damage is being counted at multiple levels – even as some limited funding flows are being restored.

For the country, the fallout has heightened civil society’s calls for a prompt, implementable plan to fill the gaps in care and services. Also needed, they say, is clarity on longer-term strategies for greater self-sufficiency in the country’s HIV responses as donor-funded models look increasingly precarious. Such an argument for increased independence in Africa and the global south was made by president of the South African Medical Research Council (SAMRC), Professor Ntobeko Ntusi, writing in the journal Nature.

South Africa should have been better prepared and not caught off guard to be left in the position it now finds itself in, some beneficiaries of US-funded projects told Spotlight. They were speaking on condition of anonymity, given the risk of public comments jeopardising their prospects of having their funding restored.

The immediate need is to ensure that the country’s overburdened and under-resourced public clinic system is able to absorb the tens of thousands of people living with HIV who will have to use public facilities. This is partly because the NGOs they have relied on have been forced to close shop – virtually overnight. Clinics catering to specific groups, such as men who have sex with men, have been particularly hard hit.

South Africa is the largest global recipient of President’s Emergency Plan for Aids Relief (PEPFAR) funds. These funds make its way to South Africa through the United States Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC). Through PEPFAR, USAID has been funding and supporting local NGOs and our Department of Health for around two decades. According to USAID’s website, it invested $5.6 billion (roughly R100 billion at the current rand/dollar exchange rate) between 2004 and 2020 towards prevention and treatment of HIV and TB in South Africa.

Trump’s initial executive order, signed on 20 January, halted funding received via USAID. USAID is an agency of the US government that now falls under the State Department under the leadership of Secretary of State Marco Rubio. Since taking office, Trump has slated USAID as “corrupt” and run by “radical left lunatics”.

The Washington head offices of USAID were closed on Friday 7 February as per Trump’s orders and even as the 90-day review period had just got underway, signage on the building was being removed or taped over. Trump’s actions have now been challenged in courts with successful temporary blocks to his orders to place 2 200 USAID workers in the US on paid leave and to reinstate 500 US-based staff who were already placed on administrative leave from when the order was first signed. The situation is highly fluid and several court actions remain in progress.

Some limited relief

In South Africa, NGOs that received USAID funding remain largely in limbo. Although the United States mission in South Africa confirmed that some PEPFAR-funded services could continue in the country, it is subject to some relatively strict limitations and with no assurances of longer term support. As is clear from reporting by Bhekisisa, the process to get at least some funding to flow again to PEPFAR-supported projects is not straight forward.

There was some good news this week linked to PEPFAR-funding channelled through the CDC – a US federal agency under the Department of Health and Human Services. Following a court order, organisations getting these funds should for now be able to continue their work. However, the court process is far from over and the future prospects of NGOs that depend on CDC funds remains precarious.

Given these ongoing uncertainties and severe disruptions to cash flows, Spotlight understands that some large NGOs may have to close down, while others may have to drastically reduce their services. As reported by Spotlight and GroundUp, several NGOs have appealed to the private sector for assistance. As it stands, thousands of people employed or contracted by local NGOs face the loss of their jobs, cut-backs and deepening anxiety over income security. These people include community health workers, peer counsellors, patient navigators, community activists and advocates, support and administrative staff members, and contract workers who keep these organisations functioning.

At stake too are specialised services for so-called key populations such as sex workers, men who have sex with men, the LGBTQI+ community, and people who use drugs. Until recently, a focus on improving services for key populations was generally accepted, including by PEPFAR, to be the right strategy given the disproportionate risk of HIV infection in these groups. But under the Trump administration’s “anti-woke” agenda, it seems likely that many services aimed at key populations are set to be defunded.

A White House media note on 29 January made clear the US’s stance: “The previously announced 90-day pause and review of U.S. foreign aid is already paying dividends to our country and our people. We are rooting out waste. We are blocking woke programs. And we are exposing activities that run contrary to our national interests. None of this would be possible if these programs remained on autopilot.”

A timeline of the US aid cuts

20 January

90-day pause 

In an executive order, US President Donald Trump orders a 90-day pause in US foreign development for “assessment of programmatic efficiencies and consistency with United States foreign policy”. 

26 January

USAID funding paused 

US Secretary of State Marco Rubio pauses all US foreign assistance funded by or through the State Department and US Agency for International Development (USAID) for review. 

28 January

Waiver issued 

Subject to certain conditions, Rubio issues a waiver stating: “Implementers of existing life-saving humanitarian assistance programs should continue or resume work if they have stopped.” 

1 February

Waiver clarified 

The extent of the January 28 waiver is clarified in a memo from the US Department of State. 

5 February

Health portfolio committee briefing 

South Africa’s Health Minister Dr Aaron Motsoaledi briefs Parliament on the US funding cuts and their impact on healthcare services. 

7 February

South Africa singled out 

In an executive order applying only to South Africa, Trump orders that “the United States shall not provide aid or assistance to South Africa”. 

10 February

Waiver still applies 

The US mission in South Africa releases an FAQ in which they state that PEPFAR activities that fall under the limited waiver will resume despite the February 7 executive order. 

12 February

CDC grants reinstated 

The grants of NGOs receiving support through the CDC are reinstated following a court order issued in a US court. 

Crisis of fear, silence, and uncertainty

Spotlight understands that staff of affected NGOs have essentially been forbidden from speaking publicly about the 90-day funding freeze. Many declined to speak on the record to Spotlight, even anonymously – too afraid it might affect the decision on their funding after the 90-day review period.

According to an FAQ by the US mission in South Africa that was published on February 10, they have been communicating with the South African government, though it is not clear when this happened. Five days earlier on 5 February, Health Minister Dr Aaron Motsoaledi told Parliament’s Portfolio Committee that he had not had any official communication from the US government on the matter.

Figures from Motsoaledi’s presentation showed that in 2023/2024, PEPFAR funding to South Africa’s health department amounted to 17% of its spending on HIV. Funding totals R4.6 billion for staffing and R2.9 billion for running costs for NGOs. These NGOs include organisations working directly with people living with HIV, mobile units and youth organisations and programmes. PEPFAR focuses on the 27 districts in South Africa with the highest disease burden.

The health department did not respond to Spotlight’s questions on contingencies, or details of next steps to fill the funding gaps or how capacity and resources will be redirected to avert catastrophe. Motsoaledi did not give any of these details in his presentation to Parliament either.

What he did say was that since Trump’s executive order came into place, the health department had hosted a meeting with the provincial leads on HIV and TB; conducted assessments on the immediate impacts of the executive order; met with people living with HIV and engaged with SANAC to finalise a sustainability framework.

A collective of activist organisations, including the Health Justice Initiative, SECTION27, the Cancer Alliance, Treatment Action Campaign, Sweat, PSAM and the African Alliance, have pressed the Department of Health to create an “urgent co-ordinated emergency plan” along with an increased budget to avert a looming disaster.

The activists highlighted that despite the announcement by the Trump administration that some NGOs could apply for a waiver, many have had no practical way to do so without ways to communicate with their USAID contacts. This as USAID employees were placed under a work stop order and were shut out of their offices and denied access to their work emails.

The appeal from the collective also extends to protecting the work of academic and clinical research in the fields of HIV, TB, and cervical cancer that will also be affected by the funding freeze. As Spotlight reported, around 28% of the South African Medical Research Council’s budget for 2025/2026 was set to come from the United States government.

An ‘unreal world’

Professor Linda-Gail Bekker, chief executive officer at the Desmond Tutu Health Foundation, said Trump’s actions put in jeopardy the goal to finally have epidemic control of HIV – and right at the final hurdles.

“We have made amazing progress. And thank you to PEPFAR that helped us to get this far, but the work is not over. For the US to pull out at this point is a massive loss of investment; it’s also regression. It’s like getting to the end of a book but having the last chapters torn out before you can read it,” said Bekker.

She said PEPFAR funding has made it possible to build a formidable cohort of lay and professional people trained and dedicated to their roles that supported public healthcare in the most critical ways.

“These are individuals who distribute antiretrovirals, distribute pre-exposure prophylaxis, find and trace individuals who’ve been lost to care. They take services into communities, to outside of the health facilities, and made the effort to go the last mile to find those individuals – that is how you close down the epidemic,” Bekker said.

Her caution too is that loosening a grip on HIV control means potential surges in tuberculosis. “HIV and TB track together all the time, and an HIV epidemic that is once again out of control, almost certainly means what will follow is a TB epidemic that is out of control,” Bekker said.

Trump has created an “unreal world”, said Dr Andy Gray of the University of KwaZulu-Natal, who has also worked with the World Health Organization (WHO) in various capacities over two decades. “People are being held to ransom; and people are scared.”

“We have always been used to the oscillation between the United States’ Republican and Democratic administrations; things may be a little uncomfortable or there may be some disruption, but not this ‘let’s burn down the house’ approach taken by the Trump administration,” he said.

“There is no consideration of human rights or for human beings anywhere in the world, including America,” he added, pointing out too that the CDC has for the first time in 60 years been instructed to cease publishing weekly mortality and morbidity data, despite a breakout of avian flu (H5) in the country.

For Gray, South Africa’s strategic health response in the wake of this crisis should be to shift from a donor-funded model. His concern, however, is that with a stretched South African purse and with competing priorities, the HIV response will slip down the list.

Gray said that better self-sufficiency comes from eliminating waste, investing in employing the right people in the right jobs as well as investing in efficient systems.

He added that National Treasury will have to redirect money for the interim shortfall left by the US funding freeze, and provinces will have to step up by getting their houses in order.

South Africa, he warned, should ready itself for the “worst case scenario” once the 90-day review period is up.

SANAC response

The South African National AIDS Council (SANAC) role is meant to bring together government, civil society and the private sector to create a collective response to HIV, TB and STIs in South Africa. But if there is a crisis strategy from the council, it has not yet been announced.

SANAC head of communications, Nelson Dlamini, said that they have been left in a position of not being able to engage publicly because they haven’t had any direct communication with PEPFAR’s and USAID representatives based in Pretoria.

“PEPFAR is a government-to-government agreement and there ought to be official communication with the government of South Africa so we know what this means for our working relationship, but nothing has been forthcoming,” said Dlamini. “SANAC is a co-ordinator so we have to still coordinate. We are engaging in the background with relevant structures but we can’t say we are doing X, Y, Z till we have a sit down with PEPFAR,” he said.

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SA Health Research Facing Catastrophic Financing Cuts

On By ModernMedia
Professor Ntobeko Ntusi is the president and CEO of the South African Medical Research Council. (Photo: SAMRC)

By Catherine Tomlinson

Cuts to United States funding of health research could have “catastrophic” consequences, says Professor Ntobeko Ntusi, who is at the helm of the country’s primary health research funder. He says the South African Medical Research Council is “heavily exposed” to the cuts, with around 28% of its budget coming from US federal agencies.

After an unprecedented two weeks of aid cuts by the United States government that left HIV programmes and research efforts across the world reeling, the Trump administration took the drastic step of freezing aid to South Africa in an executive order on 7 February.

The order – which is a directive to the executive branch of the US government and holds the weight of law – was issued to respond to what the White House called “egregious actions” by South Africa. It specifically points to the Expropriation Act and the country’s accusation of genocide against Israel at the International Court of Justice as the primary reasons for the funding freeze.

While there are some limited wavers and exceptions to the cuts, Spotlight understands that these have so far been poorly communicated and many HIV services remain in limbo.

The funding cuts, following an earlier executive order issued on 20 January,  are interrupting critical health research underway across South Africa and will ultimately undermine global efforts to stop HIV and TB.

The US is a major source of financing for health research in South Africa. Many of the country’s research institutes, groups, and universities receive funding from the US through the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), USAID, and the President’s Emergency Plan for Aids Relief (PEPFAR).

Over the past few weeks, these funding sources have come under siege by the Trump administration resulting in a gaping, and most likely insurmountable financing gap, for many health research endeavors in the country.

US spending accounts for just over half (55%) of all spending on global health research around the world. In 2022, the super power spent $5.4 billion on global health research, according to Impact Global Health –  an NPO that tracks health research spending.

While the US gives money to global health research through several different government departments and programmes, the largest source of funding for global health research is the NIH. The NIH contributed 65% of global financing for HIV research between 2007 and 2022, according to Impact Global Health and 34% of tuberculosis research financing in 2023, according to New York-based policy think tank, the Treatment Action Group.

South Africa has the biggest HIV epidemic in the world in absolute terms and is among the top 10 countries in terms of TB cases per capita.

Catastrophic consequences

“South Africa is the biggest recipient of NIH funding outside of the US”, Professor Ntobeko Ntusi, president and CEO of the South African Medical Research Council (SAMRC), told Spotlight. “[T]he consequences will be catastrophic if [funding] is stopped… for science that is important for the whole world,” he said.

South Africa plays a critical role in advancing HIV science, said Ntusi, adding that “many of the major trials that have advanced our understanding of both the effective strategies for HIV management, as well as understanding the mechanisms of disease emanated from South Africa”.

People in the US, for example, are now able to access long-acting HIV prevention shots, largely because of research that was conducted in South Africa and Uganda. Research conducted in South Africa has also been critical to validating new tuberculosis treatments that are currently the standard of care across the world.

Heavily exposed

Stop work orders were sent to research groups receiving USAID funding at the end of January. These stop work orders coupled with the halting of funding have already interrupted critical HIV research efforts, including efforts to develop new vaccines against HIV.

Ntusi said that the SAMRC is currently “heavily exposed” to the halting of grants from USAID and the CDC, with research programmes supported by USAID and the CDC already being stopped.

The SAMRC’s research on infectious diseases, gender-based violence, health systems strengthening, as well as disease burden monitoring are also affected by the funding cuts.

“In addition to support for HIV research, we have significant CDC grant funding in our burden of disease research unit, the research unit that publishes weekly statistics on morbidity and mortality in South Africa,” said Ntusi. “Our health systems research unit has a number of CDC grants which have been stopped [and] in our gender and health research unit we had a portfolio of CDC funding which also has been stopped.”

Along with programmes being impacted by the halting of USAID and CDC funding, Ntusi said there will also be major staffing ramifications at the SAMRC as well as at universities.

He said that if funding from the NIH is stopped “there would be huge fallout, we just wouldn’t be able to cover the hundreds of staff that are employed through the NIH granting process”.

The SAMRC’s combined annual income from US grants (NIH, CDC and USAID) is 28% of its total earnings (including both the disbursement from the SA government as well as all external contracts) for the 2025/2026 financial year, according to Ntusi. “So, this is substantial – effectively a third of our income is from US federal agencies,” he said.

Pivot away from infectious disease?

In addition to the executive order freezing funding to South Africa, it is unknown whether the NIH will remain a dominant funder of global health. Robert F. Kennedy Jr., the US health secretary nominee, has called for cutting to the NIH’s infectious disease research spending to focus more on chronic diseases.

Looking beyond health, Ntusi said the executive order halting aid to South Africa will be felt across a range of different development initiatives such as water and sanitation, and climate change.

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