South Africa is a study in contrasts, and the 2026 public health agenda is no exception. Breakthrough HIV prevention medicine has arrived alongside US funding cuts. AI could revolutionise TB screening but drug resistance is climbing. New obesity drugs have launched but are unaffordable to nearly everyone. National Health Insurance (NHI) is law but is facing nine court challenges which may kill it. And tobacco legislation advances –maybe.
Ida Jooste and Tanya Pampalone from Bhekisisa asked various experts about their take on a few of the most pressing public health issues this year. Here’s what they said.
Obesity guidelines. Check. Anti-obesity drugs. Check. What now?
About one-third of all South Africans are obese, and in November 2025, the government released its first clinical practice guidelines for the treatment of adult obesity. It defines obesity as a chronic disease, and helps doctors decide how to treat it, from health support without weight-shaming to medicines and surgery – and now includes recommendations for GLP-1s.
Research released in early January also showed that, in clinical trials, people who used weight-loss drugs for an average of around 10 months, and then stopped using them, quickly picked up all the kilograms they lost. So, like other chronic medications, the drugs ideally need to be used lifelong.
Angela Murphy, endocrinologist
The guidelines will help educate the healthcare sector about how they approach obesity. There are many reasons why people are obese, but it’s important to understand that up to 70% of the reason is genetic. It’s not an issue of willpower. It’s a biological response to weight loss because the body wants to defend the weight it sees as normal.
The statistics tell us that a healthy lifestyle alone, on average, can possibly get up to 5% weight loss. This is where medications become incredibly valuable.
Nomathemba Chandiwana, Chief Scientific Officer, Desmond Tutu Health Foundation
Obesity is complicated, and not easy to treat because it involves our genetics, our environment and how we eat. But it’s a disease, and we need to treat it as such.
For the GLP-1s, we need political will, as we did with HIV and antiretrovirals, where our ministers came on board. You need drug-makers, so Eli Lilly and Novo Nordisk must come to the party around pricing.
Often, we think we need $100m to do anything, but awareness campaigns work. We did that a lot in the early days of HIV, and we need to do that with obesity, which means you would also be educating people about type 2 diabetes and non-communicable diseases.
The NHI will be stuck in court. And might just die there
After nearly two decades of promises, the National Health Insurance Act was signed into law in May 2024, but lawsuits have been piling up. Our latest count: nine separate court actions.
The charges are myriad: procedural flaws in the parliamentary process; inadequate public input; an unrealistic tax-based financial structure; disputes about plans for medical aid schemes; consolidation of control under the Health Minister; consistent failures in service delivery; and the blocking of access to treatment for asylum seekers and undocumented migrants.
Currently with the Constitutional Court is President Cyril Ramaphosa’s appeal to a previous ruling that required he provide, essentially, a show of his due diligence before signing. An end-of-year application from the Health Minister asked to consolidate five of the pending cases and put them on hold until the Court’s decision on Ramaphosa’s appeal.
Similar concerns are raised in a South African case study in Global Health Watch, a Lancet-published analysis of global health reform released on January 10.
The experts we spoke to say NHI progress will be stalled – mired in court throughout 2026. That is, they say, if it survives at all.
Susan Cleary, health economist, University of Cape Town
What’s been so sad about the NHI debate is that we are saying an NHI is better than a National Health Service (NHS) system, which is what we’ve got at the moment. But there are no strong grounds to suggest NHI is better; these are simply different ways of financing a health system. In fact, the NHS is an outstanding funding model.
Also, there are huge costs of change associated with that switch, and the Act itself has serious flaws. It’s written in a way that gives legal force to regulations added later – regulations that give a lot of power to the Minister. He can appoint almost everyone and this means there’s hardly any corruption safeguard.
There were many years of engagements on this, and problems were pointed out. They sat on that for years, and then it was signed with no changes, despite all the inputs.
Alex van den Heever, economist and chair of social security systems administration and management studies, University of the Witwatersrand
The NHI is technically not lawful because the objectives of the legislation itself cannot be achieved, meaning it promises outcomes that the system it creates is not capable of delivering. For example, it relies on shifting medical scheme contributions into the tax system at a time when government has no realistic capacity to raise additional tax.
Government has never done the heavy lifting required to make a proper proposal on health reform. They’ve generated no systematic analysis of the private sector, of the public sector, nothing to justify the institutional restructuring they’ve proposed; nothing on governance.
AI: Full speed ahead
Artificial intelligence (AI) is already reshaping public health – diagnosing illnesses, analysing complex datasets and uncovering patterns in research in ways humans might not even consider.
A study in Nature Genetics found AI was able to predict which people would later be diagnosed with diseases, sometimes years before doctors identified them. AI-assisted screening for TB, which has been tested in South Africa, can read and interpret chest X-rays at a speed and scale humans could never do, with the potential to quickly identify TB hotspots, a cornerstone of prevention.
The experts we spoke to were enthusiastic but cautious, warning about risks of hype and misuse. For now, they say, it remains dependent on human expertise and data quality – and they say to researchers and healthcare providers not yet using it: you’d better start.
Thomas Hartung, Johns Hopkins Bloomberg School of Public Health Professor and Editor of Frontiers in AI
Since the early 2010s, the computing power used to train leading AI systems has been doubling roughly every three months, a pace that can make this year’s AI several times more powerful than last year. Nobody can read the millions of scientific papers that are produced each year, but AI can and does not forget.
Traditional drug development typically takes 12 years and costs roughly $3bn per drug. AI-first drugs [developed and designed by AI] reached human trials in 2023 after only four years of pre-clinical development. Major companies are now increasingly using AI to speed up every single step of the [development process]; each day saved in getting a drug to market is worth at least $1m to the developer.
AI is making it possible to map how what we’re exposed to around us – like air pollution, chemicals, diet and stress – affects our health. By combining data from large population studies and routine blood and urine tests, researchers can track how these exposures affect the body over time, laying the groundwork for “digital twins” – digital stand-ins for real people that help explain how things in our surroundings can make us sick.
Siphamandla Gumede, researcher, Ezintsha, Wits University
We are already seeing people using AI as a screening tool. If you’ve got a headache, you search, “I’ve got a forehead headache”. It will probably tell you that you have a certain type of headache, that you need to seek care or a certain type of treatment.
The high-impact goal for 2026 would be to use AI to set off a fully networked public health system that will be able to link [the health profile] of someone, no matter where they are in the country. So if you went to a clinic and picked up pills, it should be seen up on the system. If you’ve missed your clinic visit, there will be [a text, call or email] telling you that.
Guido Geerts, CEO Delft Imaging Systems
A chest X-ray allows a doctor to see if you have TB. AI does it better, and faster than a radiologist. Our current AI system has read about 30m cases worldwide and has become very intelligent in recognising TB. But AI can make a mistake, like a human. And some other lung abnormalities may not be well visible.
The tobacco Bill is coming. Just not likely in its current form
Work on tobacco legislation began in 2018, but it took until August 2025 for the Tobacco Products and Electronic Delivery Control Systems Bill to wrap up public hearings.
Parliament’s health committee will now decide whether to move ahead.
The legislation bans tobacco product displays at points of sale, single cigarette sales and smoking in public areas, and mostly applies the same rules to e-cigarettes and vapes. But the industry is pushing back hardest on requirements for plain packaging and graphic warnings (saying it would encourage illicit trade) and the Bill’s ban on advertising of electronic devices.
The industry uses the term “harm reduction” to argue that the devices are “safer” than traditional cigarettes. But public health experts refute that claim and are worried about vape marketing to children.
The experts we spoke to are confident that a Bill will go through in 2026. But how it ends up is another story.
Lekan Ayo-Yusuf, head of University of Pretoria’s School of Public Health and director of the Africa Centre for Tobacco
We’ve been documenting e-cigarette use since 2010, and the trend is clear: there is a parallel increase in e-cigarette use and in smoking.
The industry is pushing back on the e-cigarette marketing ban because they say they need to (advertise) harm reduction to consumers. This is despite studies showing this didn’t matter to users, especially nicotine-naive youth who are increasingly taking up these products for their attractive designs and flavours.
The tobacco industry wants to see a Bill. But it just wants the committee to remove and rewrite. So it may be that the committee creates its own watered-down Bill and goes with that.
Corné van Walbeek, University of Cape Town Economics Professor and director of the Research Unit on the Economics of Excisable Products
Often, people think about illicit trade as (counterfeiting or) smuggling across borders. But the main source of illicit trade is easy to fix.
You’ve got multinationals talking about illicit trade: British American Tobacco, Philip Morris, JTI. They are at public hearings, very noisy, and come across as “we are your friends. We are here to support you.”
You don’t hear from the local companies – Amalgamated Tobacco, Carnilinx and Polaris (Gold Leaf Tobacco). But they are registered with the South African Revenue Service (SARS). They are, in principle, legitimate companies. But they produce, say, 1m cigarettes, and might declare 100 000.
Our best estimate is that 60% of cigarette taxes have not been fully paid. Local groups work on the principle of “let’s make as much money as we can, as quickly as we can” because at some point the government’s going to crack down. SARS could greatly reduce illicit cigarettes with supply control measures, like track and trace technology systems that monitor cigarettes from factory to shop.
TB rates declined. Now we have to keep them dropping
Over the past decade, South Africa has reduced the number of people getting TB by about 60%, driven by better testing and treatment, Yet we still have one of the highest TB rates in the world. Studies suggest that more than 50% of South Africans carry the infection without being sick, while about one in 10 of those will go on to develop an active disease, usually when something weakens their immune system.
Experts are now concerned about the rise in resistance to bedaquiline, which has been used to treat multidrug-resistant TB since 2012. Also worrying is the 15%-20% sliced out of our TB programme and uncertainty around research due to funding cuts that could quickly reverse our gains.
But breakthroughs are converging: portable digital x-rays, AI-assisted diagnostics and since 2022, targeted testing of high-risk groups, like those with HIV, regardless of symptoms. And some research in the pipeline looks promising.
Limakatso Lebina, director of clinical trials at Africa Health Research Institute
If you have TB symptoms, you are easy to find: you are sick, you go to the clinic or hospital and you will be tested. The problem is that South Africa’s first national TB prevalence survey, in 2018, showed that more than half of people found to have TB were asymptomatic.
What we don’t know is if asymptomatic people can transmit the TB bacterium. It’s become clear that TB is a spectrum of illness. Maybe everyone starts as asymptomatic, and with time can become more symptomatic. Is that what is hindering progress in the fight against TB?
That’s what we hope to find with our research.
Mark Hatherill, director of the South African TB Vaccine Initiative, University of Cape Town
The BCG vaccine given to children gives 70%-80% protection against TB in under-fives. But that protection wears off after about 10 years. This drives the cycle of the epidemic. We need a vaccine that doesn’t have to be given multiple times.
Right now, there are two leading candidates: M72/AS01E, which is showing 50% protection, and MTBVAC. Both will probably report in 2028-2029. South Africa has a “hot” TB epidemic, meaning the disease is still spreading actively in communities. Even a TB vaccine that is 30% effective could matter a great deal – far better than no vaccine at all.
HIV: Breakthrough science, strained delivery
The public health community is excited about the roll-out of lenacapavir (LEN), the six-monthly HIV prevention jab, and recent legal changes for trained pharmacists to prescribe ARVs. But the US funding cuts continue to hamper prevention and treatment.
LEN is expected to roll out by April across 360 government clinics, but the injections, donated by the Global Fund to Fight Aids, TB and Malaria, will only be enough for 456 000 people – a sliver of what might make a meaningful dent in the estimated 173 000 new yearly HIV infections. Still, it’s an important start.
The Health Department will need about R2.82bn to plug the US funding gap for this financial year, but so far has been able to raise only R753m. The cancellation of 5 800 awards means many clinics were closed, mobile testing units sit unused, more than 24 000 health workers have not been replaced, and data systems support is stalled.
Can our stretched system handle it?
Francois Venter, executive director, Ezintsha, Wits University
Most clinical services for vulnerable groups were shut down literally overnight, and have not been replaced. The remaining 25% are in danger from further cuts. These programmes were vital to HIV prevention and, until now, were one of our few health successes.
They were successful because US funding was directed at key areas, with money tied to clear actions on the ground. The tiny amount of money mobilised since then has been sent into a vague Health department pot with no plan to replace these areas.
We’re losing 20 years of successful programming to empty political rhetoric, and we will see the consequences in new infections and advanced HIV hospital presentations soon.
Simiso Sokhela, director of Clinical Research, Ezintsha, Wits University
These drugs do not work on their own, neither do prevention drugs like LEN nor antiretrovirals. Somebody has to make sure the drugs get to the people. Somebody has to educate people. Somebody has to deal with those who have pill fatigue. Someone has to deal with the marginalised communities not included in most of these processes.
If the framework is eroded, the drugs will stay on the shelves, or will be given to people who might not take them.
Linda-Gail Bekker, director of the Desmond Tutu HIV Centre and principal investigator of PURPOSE 1 trial of LEN
I’m concerned that some people think LEN is a vaccine. I understand that because people talk about shots and this is something you only need every six months. That can be positive, in that people think: I’ve been waiting for an HIV vaccine! I just need my shot, and then I’m one and done!
Or, more concerning, post-Covid, will they say, Oh, I don’t want to go near that.
It is important to educate people so they know it is like the daily oral PrEP (pre-exposure prophylaxis) pills or good old-fashioned condoms – but it stays in someone’s body for longer: six months. And after six months, it has to be re-injected, otherwise it does not keep working.
Raising a generation of people who do not have to fear they could incur a terminal disease … would be unbelievably exciting, awesome, amazing, phantasmagoric.
See more from MedicalBrief archives:
Twice-yearly anti-HIV jab added to SA’s Essentials Medicines List
Government plays for time on NHI court cases
Digital X-rays increase TB detection in asymptomatic South Africans
Tobacco Bill vulnerable to industry influence, say critics