The South African Medical Journal (SAMJ) - first published in 1884 - is a monthly, peer reviewed, general medical journal publishing leading research impacting clinical care in southern Africa.
Licensing Information The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited. Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository. Publishing Rights Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.
Strengthening system leadership for the District Health System
Those working within the South African (SA) District Health System (DHS) have various roles in addressing population health and wellbeing needs. These include motivating and co-ordinating local providers offering community, primary healthcare facility and district hospital services, including prevention and promotion services, and facilitating whole-of-government and whole-of-society collaboration with other government and social actors. These roles cannot be fulfilled by exercising traditional, command-and-control public sector managerial authority. Instead, distributed system leadership is required: a form of leadership practised by individuals and teams that enables the collective action needed to address complex health needs, and that is supported by wider organisational structures and processes. Based on a range of experience, this in-practice article presents the rationale for, and description of, system leadership within the DHS; appraises current approaches to leadership and management development in South Africa from this perspective; and outlines a system leadership development approach that offers promise for DHS and health system strengthening.
Copyright (c) 2026 L Gilson, H Schneider, B Engelbrecht, M Shung-King https://creativecommons.org/licenses/by-nc/4.0
The 6th UCT Bongani Mayosi Memorial Lecture: Fostering evidence-based humanity in the academy and beyond: Lessons from the legacy of Prof. Bongani Mayosi
Copyright (c) 2026 L Thabane https://creativecommons.org/licenses/by-nc/4.0
A turn for the worse: The impact of deteriorating healthcare spending in South Africa
The November 2023/2024 national health budget cuts represent the largest reduction in public health expenditure in South Africa’s post-apartheid history. This article critically examines the implications of these budget cuts within the context of the country’s post-apartheid health system reforms and macroeconomic strategies. Specifically, it documents the historical evolution of fiscal policies and health expenditure across three distinct periods: the 2008 - 2013 period, which witnessed a counter-cyclical fiscal strategy that improved healthcare access and began addressing apartheid-era disparities; the years 2013 - 2023, marked by economic and political instability, culminating in a national debt crisis exacerbated by COVID-19, which eroded health system resilience under fiscal consolidation policies; and the post-November 2023/2024 period, which represents a distinct threat to two decades of progress in health equity and outcomes under further fiscal consolidation measures. The article discusses the impact of these austerity measures on healthcare workers and patient populations and the implementation of the National Health Insurance, while exploring the ethical and legal implications. It concludes by proposing recommendations for system-wide reforms to mitigate the negative effects of these budget cuts and prevent systemic collapse.
Copyright (c) 2026 A Bhorat, D Nel, L Cairncross, M Visser https://creativecommons.org/licenses/by-nc/4.0
A new perspective to aid in MMed research report completion: The effort-time trajectory model
Background. Since 2011, the Health Professions Council of South Africa has required all specialist trainees to complete a Master of Medicine (MMed) research report, a requirement intended to strengthen the production of relevant local research. However, evidence shows that this expectation substantially increases trainee workload, contributes to delays in specialist registration and may impede clinical skills development. SA studies report that registrars frequently lack the time and support needed to complete research tasks, with many exceeding the nominal training period. These challenges mirror international experiences where integrating research into busy clinical programmes remains difficult. Objective. To introduce and describe the effort-time trajectory model as an innovative conceptual framework to support MMed trainees in planning and completing their research reports. Methods. We describe the effort-time trajectory model, originally developed by Nel, which complements existing scheduling-based research support models by explicitly incorporating anticipated cognitive effort. Drawing on educational theory, particularly cognitive load theory, the model conceptualises research progression as a dynamic trajectory of both practical and cognitive effort over time. Results. The model highlights predictable peaks – such as protocol development, data analysis and final writing – and lulls, such as routine data collection. Mapping these fluctuations enables early identification of periods where trainees are most vulnerable to overload and where targeted supervisory or institutional support may have the greatest impact. Conclusion. The effort-time trajectory model provides a more holistic lens for supporting MMed research training by accounting for both temporal and cognitive demands. Its application may reduce last-minute workload surges, improve research completion timelines and support more sustainable integration of research within specialist training programmes.
Copyright (c) 2026 G Nel, T Ruder, S Kauchali https://creativecommons.org/licenses/by-nc/4.0
Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection
Copyright (c) 2026 M Swart https://creativecommons.org/licenses/by-nc/4.0
Narrowing the care and treatment gap through a human resources for mental health plan: Key considerations
General medicine, Psychiatry, Psychology, Nursing
Copyright (c) 2026 M Freeman, G Wolvaardt, G Maimela https://creativecommons.org/licenses/by-nc/4.0
Evaluation of healthcare resource utilisation and costs associated with anogenital warts in South Africa
Background. Human papilloma virus (HPV), the most prevalent sexually transmitted infection worldwide, and in particular HPV 6 and 11, contribute to >90% of anogenital warts (AGW) cases, and high-risk HPV serotypes cause >95% of cervical cancers in South Africa (SA). The healthcare resource utilisation (HCRU) and costs related to AGW in SA remain poorly understood, in both the public and private sectors. Objective. To assess the HCRU patterns and associated treatment costs for AGW across the public and private sectors. Methods. A descriptive, questionnaire-based study was conducted, involving 50 subject matter experts (SMEs) from SA: 24 from the private sector and 26 from the public sector. The study explored resource use, treatment patterns and cost estimation based on SME responses. Results. Findings revealed that public-sector SMEs treated a larger volume of AGW patients per month (1 - 300) than private-sector SMEs (0 - 20). Most AGW patients were female, comprising 78% in the public sector and 72% in the private sector. The occurrence of AGW was higher in the public sector, ranging between 21.4% and 34.4%, while in the private sector, the occurrence ranged from 13.1% to 23.2%. The weighted cost per patient per episode was higher for females than males in both sectors. In the private sector, costs were ZAR22 482 for females and ZAR17 812 for males, while in the public sector, costs were ZAR19 220 for females and ZAR14 271 for males. The higher costs for females were driven by invasive diagnostic procedures, including vulvar colposcopy and biopsy, and a higher frequency of medical visits (2.0 - 4.4 visits in the public sector). Recurrence rates of AGW were reported at 37.6% in the private sector and 43.9% in the public sector. The total estimated treatment cost of AGW was notably higher in the public sector for both males (ZAR93.6 - ZAR138.5 billion) and females (ZAR135.2 - ZAR207.7 billion), compared with the private sector (males: ZAR11.0 - ZAR19.4 billion; females: ZAR16.7 - ZAR28.3 billion). Female patients experienced a higher burden of diagnosis, recurrence and complications than males. Conclusion. AGW imposes a substantial burden on SA’s healthcare system, particularly in the public sector, where female patients face significant costs and complications. The use of a quadrivalent or nonavalent HPV vaccine, rather than a bivalent vaccine, could reduce the impact of AGW and its associated healthcare demands.
Anogenital warts, HPV, Anogenital diseases, Healthcare costs, Healthcare resource utilisation, South Africa
Anogenital warts, HPV, health care resource utilization
gynaecology, urology, general medicine, dermatology, pathology
Copyright (c) 2026 S Mutambirwa, M H Botha, B M Mulaudzi, M S Mabenge, T Gaqana https://creativecommons.org/licenses/by-nc/4.0
Opportunities for health system strengthening to reduce preventable trauma deaths in the Western Cape Province, South Africa: Findings from an expert panel review
Background. Injuries are a leading cause of death and disability worldwide, and disproportionately affect young persons (aged 15 - 49 years) residing in low- and middle-income countries. Panel reviews of trauma deaths are an effective way to identify areas for improvement within a health system. Objectives. To assess the preventability of trauma deaths that had contact with the health system, and the associated panellists’ recommendations for improvements. Methods. A comprehensive review of injury-related deaths identified by an epidemiological study was conducted in the Western Cape Province of South Africa in April 2022. Panellists identified contributing factors and opportunities for improvement for each case. Investigators assigned a thematic code to each opportunity for improvement, and codes were categorised and mapped into a matrix organised according to the applicable level of the health system and the descriptive category for improvement. Results. Twenty-three multidisciplinary expert panellists reviewed 90 injury deaths that occurred in 2021. The largest proportion of deaths was from firearms (30%), and 41 (45%) of the 90 cases were found to be preventable or potentially preventable. The median time from injury to death was 41.4 hours for rural injuries, compared with 12.9 hours for urban injuries. Conclusion. Key recommendations from the panel included training in basic trauma resuscitation, and increased access to patient monitoring, operating theatres, radiology and intensive care beds. Panellists further recommended implementation of injury primary prevention strategies in the community.
Trauma Surgery, Thoracotomy, Emergency Care, Injury
Surgery, Trauma, Cardiothoracic surgery, Vascular Surgery
Copyright (c) 2026 J Dixon, S de Vries, S Bhaumik, C Dymond, M Ross, J Finn, H Geduld, E Steyn, H Lategan, L Hodsdon, J Verster, S Mukonkole, K Doubell, N-K Mould-Millman https://creativecommons.org/licenses/by-nc/4.0
Copyright (c) 2026 A Dhai https://creativecommons.org/licenses/by-nc/4.0
The Life Esidimeni tragedy: A decade later
Routine blood monitoring in acne vulgaris patients on isotretinoin: Is reassessment warranted? A retrospective cohort study from Tygerberg Hospital
Background. Oral isotretinoin is an indispensable treatment for patients with resistant and severe acne vulgaris, both in South Africa (SA) and globally. While routine laboratory monitoring is often deemed unnecessary for young, healthy patients, it remains unclear whether this applies in the SA context. Objectives. To assess the need for routine blood monitoring for acne vulgaris patients on isotretinoin treatment at Tygerberg Hospital, SA. Specifically, we wanted primarily to determine the prevalence of patients with acne vulgaris whose oral isotretinoin treatment was altered owing to blood result abnormalities, and secondarily, to determine the prevalence of adverse events and liver function and lipid profile abnormalities associated with isotretinoin. Methods. This was a retrospective cohort study of hospital records from patients with acne vulgaris treated with oral isotretinoin at the dermatology clinic at Tygerberg Hospital between 1 January 2020 and 31 December 2023. There were 89 eligible records extracted from the Tygerberg Hospital Enterprise Content Management system. Baseline and 6-week follow-up laboratory data, including liver function tests and lipid profile, were extracted retrospectively from the National Health Laboratory Service. Results. The sample comprised 89 patient hospital records, 62% male and 38% female. Of the total, 53% were aged between 12 and 20 years. Blood result abnormalities led to alterations in treatment regimens for 2/89 (2.2%) patients: one patient required treatment termination, while another continued on low-dose isotretinoin instead of the planned dose increase. Two patients (2.2%) developed increased aspartate aminotransferase levels and five (5.6%) developed new alanine aminotransferase increases above the upper limit of the normal range. Elevated triglyceride levels occurred in two patients (2.2%), and elevated cholesterol levels in nine (10.1%). Adverse events resulting in the premature termination of treatment with isotretinoin included one case of severe chest pain, one patient with pseudotumour cerebri and one patient who developed exuberant granulation tissue. Conclusion. This single-centre retrospective review highlights the scarcity of blood result abnormalities due to isotretinoin in patients with acne vulgaris. There were only two patients (2.2%) who had their management altered owing to blood result abnormalities, and both had chronic conditions. This may suggest that routine monitoring is indicated in patients with comorbidities, but not in otherwise healthy young patients with acne. However, larger prospective studies are needed in SA before such conclusions can be drawn.
Acne vulgaris, Isotretinoin use, laboratory monitoring, blood result abnormalities
Acne vulgaris, Isotretinoin, laboratory monitoring, lipid profile, hepatic enzymes, cost-saving, resource-constrained, South Africa
Copyright (c) 2026 J du Toit, N A Gray, T M Esterhuizen, W I Visser https://creativecommons.org/licenses/by-nc/4.0
Best interests above belief: Constitutional guidance for life-saving medical decisions involving children
Red Cross War Memorial Children’s Hospital v MD and Another
Copyright (c) 2026 S Mahomed https://creativecommons.org/licenses/by-nc/4.0
Prevalence and socioeconomic determinants of post-acute sequelae of SARS-CoV-2 among individuals from a peri-urban township and an informal settlement in Johannesburg, South Africa
Background. Individuals infected with SARS-CoV-2 who develop COVID-19 are susceptible to persistent symptoms and sequelae, referred to as post-acute sequelae of SARS-CoV-2 (PASC). The prevalence of PASC is estimated to range between 10% and 30%. However, there is a paucity of data from African countries. Objectives. To investigate the prevalence and sociodemographic determinants of PASC in a peri-urban township and an informal settlement in South Africa (SA) during the COVID-19 pandemic. Methods. A prospective cohort study was conducted among individuals residing in sampled households within the Soweto and Thembelihle Health and Demographic Surveillance System in Gauteng Province, SA. Between August 2021 and January 2022, all individuals from 214 sampled households were tested for SARS-CoV-2 and followed up for 6 months for symptoms. The prevalence of PASC, defined as persistence of symptoms through to at least 30 (PASC-30) and 90 (PASC-90) days, was evaluated, and determinants of PASC were identified using logistic regression models. Results. There were 268 individuals with documented COVID-19 illness identified, of whom 65.3% (n=175) were female. The median age was 24 years. The overall prevalence of PASC-30 was 23.9% (95% confidence interval (CI) 19.2 - 29.3), including 24.6% (95% CI 19.7 - 30.3) and 12.5% (95% CI 3.5 - 36.0) in individuals who were unvaccinated or had received a COVID-19 vaccine, respectively (p=0.283). The overall prevalence of PASC-90 was 2.2% (95% CI 1.0 - 4.8). Factors associated with PASC-30 included living in an informal (39.2%, 105/268) v. formal settlement (60.6%, 163/268) (adjusted odds ratio (aOR) 4.1, 95% CI 2.1 - 8.3), although participants living in larger households (aOR 0.8, 95% CI 0.7 - 0.9, p=0.011) were less likely to report PASC-30 than those from smaller households. Age, gender, marital status, level of education, employment status, vaccination status and the presence of comorbidities were not significantly associated with PASC. Conclusion. PASC-30 (23.9%) was prevalent at the population level in individuals with documented COVID-19, particularly among residents of informal settlements, while PASC-90 (2.2%) was low. Further exploration into PASC within informal settlements is imperative to comprehensively understand these findings.
South Africa, Soweto, peri-urban, HDSS, long-COVID
Health and Demographic Surveillance System
Copyright (c) 2026 T Machemedze, P Mutevedzi, A Izu, N Myburgh, C Verwey, S Mahtab, Z Dangor, S Madhi https://creativecommons.org/licenses/by-nc/4.0
Opportunities to expand delivery of prehospital tranexamic acid to bleeding trauma patients – findings from a prospective multicentre trauma study in the Western Cape Province, South Africa
Background. Traumatic haemorrhage is a leading cause of preventable injury-related deaths. Tranexamic acid (TXA) has demonstrated a 38% all-cause mortality reduction when administered to severe haemorrhagic shock patients in South Africa (SA). Yet its prehospital utilisation in SA remains limited owing to prehospital provider qualification restrictions, despite the region’s high trauma burden. Among the 4% of prehospital providers licensed to administer TXA, prehospital eligibility and TXA administration is poorly reported. This utilisation gap suggests multifactorial barriers beyond the current scope of practice restrictions that impede effective implementation of this evidence-based intervention. Objective. To assess patterns of TXA administration and omission during prehospital emergency care in the Western Cape Province, SA. Methods. This is a secondary analysis from the EpiC prospective multicentre study. The current study examined 4 094 patients at risk of haemorrhage in the Western Cape from August 2021 to December 2024. First, we assessed patient and injury characteristics as well as prehospital and hospital treatments among three prehospital treatment groups: those who received TXA; those who received a lifesaving circulation intervention and no TXA; and those who received neither. Second, a subset of patients was selected for three clinical scenarios: patients with moderate to severe risk of shock; those with severe shock meeting TXA eligibility criteria; and those requiring hospital-based interventions for haemorrhage. Prehospital provider qualifications, clinical interventions and outcomes were assessed using descriptive statistics, and Sankey diagrams were used to visually depict the quantity and flow of prehospital trauma patients stratified by prehospital provider qualification. Results. Only 2.8% (n=116) of all haemorrhage-risk patients received prehospital TXA despite 82% (n=3 325) presenting within the 3-hour window for administration. Among eligible patients with severe risk of shock who were managed by an advanced prehospital provider (n=161), only 19% (n=30) received TXA. Basic and intermediate prehospital providers, who cannot administer TXA under current regulations, managed 67% (n=326) of these patients. These providers frequently delivered other life-saving circulatory interventions (70 - 79%). Conclusion. This study reveals that only a small percentage of eligible trauma patients receive TXA despite its established mortality benefit. The principal barrier identified is the current scope-of-practice restriction preventing basic and intermediate prehospital providers from administering TXA, despite managing two-thirds of eligible patients and possessing the knowledge and skills to deliver TXA. We strongly recommend that the scope of TXA be extended to intermediate prehospital providers in SA.
Copyright (c) 2026 N Abdullah, J Young, W Stassen, C Wylie, H J Lategan, G Oosthuizen, S de Vries, J Verster, EpiC Study Site Collaborators, J M Dixon, N-K Mould-Millman https://creativecommons.org/licenses/by-nc/4.0
Prevalence of alcohol use, associated risk factors, and the impact on the HIV care cascade among adolescent girls and young women in South Africa: Findings from the HERStory Study
Background. High rates of hazardous and binge drinking patterns have been identified among adolescent girls and young women (AGYW) in South Africa. AGYW also bear the highest burden of HIV/AIDS in the country, placing them at increased risk of negative outcomes for both HIV and alcohol. Objectives. To estimate the prevalence of alcohol use and describe the patterns of use for AGYW enrolled in the HERStory Study. Secondary aims included identifying covariates of alcohol consumption and examining the impact of alcohol use patterns on the HIV care continuum. Methods. We included all 4 377 AGYW (aged 15 - 24 years) enrolled in the HERStory baseline survey from six high HIV-risk districts. Alcohol consumption was assessed using the abbreviated Alcohol Use Disorders Identification Test, the AUDIT-C screening tool, with a score of ≥2 indicating hazardous drinking, while binge drinking was defined as consuming ≥6 drinks on one occasion at least monthly. Results. Among participants, the median (interquartile range) age was 19 (17 - 21) years; 57.2% attended school, 82% were of low socioeconomic status and 66.3% self-reported as HIV negative. The prevalence of alcohol use was 32.2% and was highest among women aged 20 - 24 years (36.1%) and among those living in the Cape Town and Tshwane districts (52.8% and 51.6%, respectively). Of the 1 394 participants who reported ever drinking, 50.6% reported hazardous drinking and 22.7% binge drinking. Hazardous drinking was associated with residence in Cape Town district (odds ratio (OR) 2.25) and absence from school (OR 1.42) in univariate analyses. The odds of binge drinking were 2 - 7 times greater in all districts compared with King Cetshwayo in univariate analyses, and remained significant in the multivariate analysis. No association was found between hazardous or binge drinking and HIV care outcomes. Conclusion. The prevalence of alcohol use was elevated in the population of young women aged 20 - 24 years. Hazardous and binge drinking patterns were common in most districts and among those not attending school. Efforts to address the risk of drinking in this age group could focus on increased screening of AGYW for alcohol use, and supporting school attendance and after-school activities.
Copyright (c) 2026 M R Tlali, M A Davies, C Lombard, C Mathews, C D Parry https://creativecommons.org/licenses/by-nc/4.0