A roadmap for kidney health for South Africa in the context of universal health coverage

Chronic kidney disease (CKD) in South Africa (SA) is a growing public health crisis, driven by the intersecting burdens of HIV, tuberculosis, hypertension, diabetes and obesity. In Black African populations, high-risk apolipoprotein L1 (APOL1) variants add a genetic predisposition to non-diabetic kidney diseases, compounding risk. Global recognition of CKD has recently advanced, marked by the 2025 World Health Organization (WHO) non-communicable disease resolution, which urges the integration of kidney care into national health strategies. This resolution emphasises prevention, early detection and treatment, while strengthening primary healthcare and addressing social determinants of health, particularly in low-income countries. However, in SA, domestic capacity has not kept pace. Public-sector dialysis slots have remained static since 1994, while the private sector has expanded rapidly, deepening inequities by province and income. In the public sector, dialysis is rationed to patients eligible for transplantation, yet transplant access is limited by organ shortages, logistical barriers and variable provincial resources. Expanding deceased donation and implementing kidney paired donation (KPD) programmes are essential to increase transplant opportunities, particularly for incompatible donor- recipient pairs, and to improve equity in access. Children and adolescents face additional barriers, including limited age-specific pathways and the absence of structured transition to adult care. Workforce shortages, inadequate regulatory oversight, inconsistent procurement processes and incomplete registry reporting undermine service quality, limit expansion and perpetuate inequities in access. Without urgent reform, CKD will continue to drive preventable morbidity, premature mortality and escalating costs. Scaling equitable dialysis and transplantation services, integrating KPD and investing in prevention, workforce and infrastructure are critical to reversing current trends and fulfilling the WHO's call for action.