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Confronting COVID-19 and health system inequalities in SA

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Confronting COVID-19 and health system inequalities in South Africa: Missed opportunities for inclusive health policies?

by Dr Laetitia Rispel [BSc(Cur), PG Dip, BScHons, MSc(Med), Phd], Ms Shehnaz Munshi [BSc(OT), MPH] and Dr Candice Bailey [B.Tech(Journalism), MA (Political Studies), Phd(Political Studies)]


Amidst South Africa’s socio-economic inequalities, by 27 September 2021, the country reported around 2, 9 million confirmed COVID-19 cases and more than 87 000 deaths.

In this article, we use a systems perspective to explore the health system inequalities exposed and amplified by the COVID-19 pandemic, and the missed opportunities for the development or implementation of inclusive health policies. In the first section of the paper, we present our framework of analysis and selected features of the South African health system before the COVID-19 pandemic. In the second section, we summarise the government’s policy response to the pandemic and present the cumulative COVID-19 statistics in South Africa. In the third section, we use our analytical framework to illustrate that COVID-19 exposed or amplified inequalities in the health system. We also highlight the missed opportunities in the development and/or implementation of more inclusive health policies.

We conclude the paper with four recommendations to move towards a more equitable and inclusive health system in South Africa. Firstly, strong and competent leadership, a capable state and public health service are critical for equity. Secondly, investment in human resources for health and thirdly, the involvement of civil society and communities in the COVID-19 response, both to advance social justice, prevent corruption, and to ensure the right to health care services. Lastly, we recommend the development and publication of select equity indicators to assist us in moving towards an equitable health system.


The novel Coronavirus disease 2019 (COVID-19) pandemic is a global public health emergency. By 27 September 2021, there were more than 200 million confirmed cases globally and around 4.8 million deaths were reported to the World Health Organization (WHO) (WHO 2021). Apart from the suffering and devastation, COVID-19 has laid bare and amplified the pre-existing social and economic injustices both within and among countries and regions (Abrams and Szefler, 2020; Adebisi et al., 2020; Chiriboga et al., 2020).

In South Africa, by 27 September 2021, around 2, 9 million confirmed cases of COVID-19 and more than 87 000 deaths were reported to the WHO (WHO, 2021). These statistics should be seen in the context of the pre-existing socio-economic inequalities in the country. Notwithstanding a rights-based constitution, South Africa remains one of the most unequal countries in the world, with a 2020 Gini coefficient of 63.0 (UNDP, 2020).

The pandemic has widened pre-existing socio-economic inequalities between urban and rural areas (Visagie & Turok, 2021) and within cities between townships and suburbs (Turok & Visagie, 2021), thus exacerbating the glaring spatial inequalities created by apartheid (Todes & Turok, 2018). In the context of these spatial and infrastructure inequalities, De Groot and Lemanski (2021) have criticized the universality of public health measures such as self-isolation and social distancing that make it almost impossible for poor people in dense, overcrowded areas to comply with COVID-19 regulations. The 2020 National Income Dynamics Study (NIDS) – Coronavirus Rapid Mobile Survey (CRAM) has demonstrated that the impact of the measures used to combat the COVID-19 pandemic (e.g. the lockdown) has been uneven, exacerbating socio-economic inequities by race, gender and geography (Spaull et al., 2020).

The pandemic has also exacerbated gender inequalities, with women experiencing two-thirds of the net job losses between February and April 2020 and a larger decrease in working hours compared to men (Casale & Posel, 2021). Furthermore, women assumed greater responsibility for childcare resulting from the school closures during the pandemic (Casale & Posel, 2021), and dramatic spikes in the number of gender-based violence cases reported to the police during lockdown (Nduna & Tshona, 2021). The COVID-19 pandemic also worsened income-related health inequalities, which were higher among women, black Africans and households that experience hunger (Nwosu & Oyenubi, 2021).

We recognise that the health system is both a social determinant and affected by other social determinants such as education and employment. However, in this article, we use a systems perspective to explore the health system inequalities exposed and amplified by the COVID-19 pandemic, and the missed opportunities for the development or implementation of inclusive health policies. In the first section of the paper, we present our analytical framework and selected features of the South African health system before the COVID-19 pandemic. In the second section, we summarise the government’s policy response to the pandemic and present the cumulative COVID-19 statistics in South Africa. In the third section, we use our analytical framework to illustrate that COVID-19 exposed or amplified inequalities in the health system. We also highlight the missed opportunities in the development and/or implementation of more inclusive health policies. We conclude the paper with four recommendations to move towards a more equitable and inclusive health system in South Africa.

Analytical framework

In 2000, the seminal World Health Report placed a spotlight on the performance of health systems, underscoring their fundamental goals of improving population health outcomes, and ensuring community responsiveness and efficiency of resource utilisation (WHO, 2000). A health system is defined as “all organisations, people, and actions whose primary intent is to promote, restore, or maintain health, including the organisation of people, institutions, and resources that deliver health care services, as well as intersectoral action to address the determinants of health” (WHO, 2007). The WHO health systems framework describes six core components or “building blocks”, namely service delivery; human resources for health (HRH) or the health workforce; health information systems; medical products, vaccines and technologies; financing; and leadership and governance (WHO, 2007). The building block of leadership and governance combines the existence of strategic policy frameworks, effective oversight, coalition-building, regulation, system design and accountability (WHO, 2007). It is considered the most important component because it is a critical enabler of the other building blocks and the achievement of the health systems goals (WHO, 2000; WHO, 2007). Several authors have highlighted the importance of government leadership and governance (or stewardship) for policy direction, regulating the behaviours of policy actors, health intelligence, management of health crises, and/or resource allocation (Marchildon & Bossert, 2018; WHO, 2000; WHO, 2007).

Building on the WHO health systems building blocks, in 2012 Van Olmen and colleagues introduced the health system dynamics framework (HSDF) (van Olmen et al., 2012). The HSDF draws on the notion of complex adaptive systems and underscores the importance of values in shaping the actions and behaviours of health policy actors (van Olmen et al., 2012). The framework also highlights the dynamic interactions among the context, the various policy actors, values, health system building blocks, levels and goals, and population health outcomes (van Olmen et al., 2012).

In 2019, the South African Lancet National Commission adapted van Olmen’s HSDF (Figure 1) to define a high-quality health system as one that achieves equity, longevity and population health outcomes (South African Lancet National Commission 2019). In concert with both WHO (WHO, 2007) and the HSDF (van Olmen et al., 2010), the Lancet Commission’s framework underscores the criticality of leadership and governance for a high-quality health system, while the anticipated impact is a healthy South African population, equity in the level and distribution of health outcomes, and social and financial risk protection (South African Lancet National Commission, 2019).

We use this framework of the South African Lancet National Commission (Figure 1) to illustrate the health system inequalities, amplified by the COVID-19 pandemic.

Figure 1: Conceptual framework for a high-quality South African health system

(Source: South African Lancet National Commission, 2019).

South Africa’s health care system before COVID-19

The historical context of South Africa’s health care system is the legacy of apartheid with its deep roots of structural and systemic inequalities (Coovadia et al., 2009; Mooney & McIntyre, 2008; The Presidency, 2019). Apartheid created a highly fragmented and racially divided health care system, with huge inequities in the distribution and allocation of resources, bias towards curative and hospital-based services, lack of prioritisation of primary health care (PHC), neglect of the diseases of poverty, and of the health of the black majority (The Presidency, 2019).

The 1997 White Paper for the Transformation of the Health System envisioned a:

Unified health system capable of delivering quality health care to all our citizens efficiently and in a caring environment. The strategic approach guiding us in this endeavour is that of Comprehensive Primary Health Care” (Department of Health, 1997).

The National Health Act provides the legal framework for health sector transformation (RSA, 2004), while the Constitution makes provision for the progressive realisation of the right to health care services, including reproductive health care (RSA, 1996).

Since 1994, the South African government has implemented a raft of legal, structural and policy changes and various priority health programmes, boasting the highest anti-retroviral treatment programme in the world (The Presidency, 2019). Although South Africa’s progress since the end of apartheid is reflected in an increased life expectancy, reductions in mortality rates, policy prioritisation of PHC, and improved access to health care, the democratic government continues to face significant challenges in providing high-quality health care (Rispel et al., 2019). Progress is marred by the quadruple burden of disease, weaknesses in leadership and management, corruption, as well as the pre-existing health system inequities among provinces, between urban and rural areas, and between the public and private health sectors (Rispel et al., 2019; The Presidency, 2019).

Table 1 shows selected features of the health care system prior to the COVID-19 pandemic.

Table 1: Selected features of South Africa’s health care system before COVID-19
(Sources: National Department of Health, 2020; Republic of South Africa, 1996; Rispel et al., 2019; The Presidency, 2019; World Bank, 2018).

COVID-19 and government policy responses

South Africa is widely praised for its quick response to the COVID-19 pandemic (Hale & Webster, 2020). In March 2020, South Africa declared a national state of disaster, followed by a stringent lockdown that involved restrictions on movement, a travel ban, and the halting of all non-essential economic activity (COGTA, 2020). Guided by the WHO, the National Department of Health (NDoH) developed a multi-sectoral approach to contain and mitigate the spread of COVID-19. Table 2 summarises the key elements of the national COVID-19 response (Abdool Karim, 2020; Moonasar et al., 2021).

Table 2: Key elements of the national COVID-19 response
(Sources: Adapted from Abdool Karim, 2020; Moonasar et al., 2021).

On 28 September 2021, South Africa entered day 551 of lockdown, with the country experiencing three epidemic waves between March 2020 and September 2021, and administering close to 17 million vaccines.

Figure 2 presents an overview the COVID-19 statistics as of 27 September 2021.  

Figure 2: Covid 19 statistics in South Africa as of 27 September 2021
(Source: NDoH, 2021).

COVID-19, the health system, inequities and missed opportunities Context The COVID-19 pandemic has exposed the fault-lines of South Africa’s health system, especially the vulnerabilities of the public health sector (Burger et al., 2021; Nyasulu and Pandya, 2020; Oxfam South Africa, 2020; Pillay et al., 2021; Rispel, 2021; TAC, 2021). The overwhelming, negative effects of the pandemic on the public health system have been due to a combination of pre-existing system weaknesses, leadership failures, corruption, the diversion of financial and human resources, suspension of routine services and a deterioration in information collection and management (Hofman & Madhi, 2020; Nyasulu & Pandya, 2020; Oxfam South Africa, 2020; TAC, 2021). In this section, we use the South African Lancet Commission’s Framework, described in the previous section, to illustrate that the COVID-19 pandemic exposed or amplified inequalities in the South African health system (Figure 3). We also highlight the missed opportunities in the development and/or implementation of more inclusive health policies.

Figure 3: Illustration of health system vulnerabilities, inequalities and missed opportunities in the Covid-19 response

Leadership and governance Section 27(2) of the Disaster Management Act makes provision for the state to make regulations or issue directions for the purpose of assisting and protecting the public, providing relief to the public and/or dealing with the effects of a disaster (COGTA, 2020). Although regulations were passed to strengthen public health measures (e.g., masking, sanitation, gatherings), the NDoH missed an opportunity to ensure a unified and integrated national response to the pandemic. As shown in Table 2, the NDoH developed a national COVID-19 response (Table 2) (Abdool Karim, 2020; Moonasar et al., 2021). However, in practice, each provincial health department and metropolitan local government health department developed and/or implemented its own response. There were differences between the public and private health sectors in COVID-19 hospital admission criteria and treatment and care. We argue that the NDoH missed an opportunity to provide strong central leadership (Rispel, 2021), with equity as a core value and principle of the COVID-19 pandemic response. Consequently, the sub-optimal leadership negatively affected the health system building blocks such as HRH, service delivery and the outcomes (Figure 3).

The lack of leadership was particularly evident when reports of corruption in the procurement of personal protective equipment (PPE) emerged within three months of the pandemic being declared in the country (SIU, 2021a). Almost a year after the PPE corruption scandal, the SIU presented a report to the president of further irregularities and corruption in the procurement processes in respect of the COVID-19 media campaign, referred to as the Digital Vibes scandal (SIU, 2021b). Subsequently, the then Minister of Health resigned (Khoza & Skiti, 2021), while the National Health Director-General was suspended on 26 September 2021 (Molosankwe, 2021). This reported corruption is a reflection of failed leadership, management and governance, exacerbated by a culture of poor accountability and unethical behaviours. Health service delivery The COVID-19 response has revealed how the [in]action of those in power and governance has the potential to impact positively or negatively on the health and livelihoods of citizens (Cooper & Kramers-Olen, 2021). The response has largely centred on hospitals, with relative neglect of PHC, and resultant reductions in utilisation of PHC services (Adelekan et al., 2020; Burger et al., 2021; Pillay et al., 2021). Burger and colleagues illustrated a reduction in PHC utilisation across almost all districts in the country irrespective of the actual district-level incidence risk of COVID-19 (Burger et al., 2021). They highlighted that COVID-19 fears among communities negatively affected access to preventive services, such as HIV testing and maternal and child health services (Burger et al., 2021). In a survey among uninsured people, almost a quarter (23%) reported that they did not seek care for acute conditions when needed, mostly due to fear of contracting the virus (Burger et al., 2020). Furthermore, this reduced access to preventive services disproportionately affecting the poorest and most vulnerable groups, thus exacerbating health care and other socio-economic inequities (Burger et al., 2021). Pillay and colleagues also found that antenatal visits before 20 weeks, access to contraceptives, and HIV and TB testing were adversely affected, with variations by province and district (Pillay et al., 2021). They highlighted the increases in maternal and neonatal mortality in many provinces that reflect both the direct and indirect impact of COVID-19 (Pillay et al., 2021). These increases in mortality of women and neonates are of concern, reversing the gains made in the preceding 27 years since democracy (Bamford et al., 2018; Moodley, Fawcus & Pattinson, 2018). Furthermore, the long-term negative consequences of the reduced or lack of access to sexual and reproductive health services might only be seen in future (Adelekan et al., 2020; Pillay et al., 2021). Given South Africa’s HIV burden, 24% of people living with HIV said that they were unable to access their antiretroviral medications (TAC, 2021). We argue that the government missed the opportunity to strengthen PHC, which is the foundation of South Africa’s health system. Furthermore, the relatively top-down approach with highly centralised decision-making structures failed to involve communities and draw on their wisdom and experience in the COVID-19 pandemic response. Health system building blocks/inputs A lack of leadership in relation to the health system building blocks is another missed opportunity, with the COVID-19 pandemic exposing the negative consequences of the chronic under-investment in HRH, especially in frontline health workers (Cooper & Kramers-Olen, 2021; Rispel et al., 2018). HRH are central to a responsive and well-functioning health system. However, the COVID-19 response has missed the opportunity to engage with health workers or facilitate their participation in the evolution or design of the response. A 2020 Oxfam report noted that “ignoring the wellbeing of healthcare workers has left a healthcare system on its knees, with front line workers stretched while in a battle to restore health” (Oxfam South Africa, 2020). By 17 February 2021, 40 000 South African health workers had contracted COVID-19 (NDoH, 2021). Tragically, by the end of August 2021, 1 297 health workers had lost their lives due to the pandemic (Heywood, 2021a). Among the risk factors for in-hospital Covid-19 mortality among health workers are: age 40 years and older, male sex, black African and Indian race, the presence of comorbidities, and being admitted in the rural provinces of Eastern Cape, Limpopo and Northern Cape (Heywood, 2021a). These rural provinces can least afford to lose health workers, given the inequitable distribution of health workers. Female health workers are also affected disproportionately by the pandemic, as they constitute the vast majority of those on the frontline. This is illustrated by a 2021 study that examined COVID-19 infections among PHC service providers of an NGO in five South African districts. The study found that 14% of the 4 000 staff members had been diagnosed with confirmed COVID-19 between April and September 2020 (Rees et al., 2021). The majority of infections (78%) were among women (Rees et al., 2021). The authors highlighted the higher risk of COVID-19 infection among community health workers because of their gender, poor infrastructure, limited training and experience of infection prevention and control, and insufficient power to negotiate good working conditions (Rees et al., 2021). Importantly, we argue that the chronic under-investment in HRH was worsened by the failure of the initial COVID-19 response to prioritise the needs, concerns and fears of frontline health workers and to plan for or provide psychosocial support (Rispel, 2021). Encouragingly, Phase 1 of the vaccine programme prioritised health workers (NDoH, 2021). However, we argue that a dedicated focus on HRH and state capacity to implement HRH interventions must be central to the pandemic response. Outcomes There are vast inequities in spending between the public and private health sectors, which in turn influence health care access and quality of care. The NDoH has both failed and missed an opportunity to introduce equity-oriented regulations and to ensure greater collaboration between the public and private health sectors in South Africa. COVID-19 highlighted the stark realities of inequity in access to testing, treatment and care between the public and private health sectors. Even though the private health sector provides care to less than 20% of the South African population, this sector accounts for 54% of the more than 17 million COVID-19 tests conducted since March 2020 (NICD, 2021). Furthermore, evidence suggests that there is a lower threshold for admission to private hospitals, thus exacerbating inequities in access to COVID-19 treatment and care (Jassat et al., 2021). Conclusion We have shown evidence that the COVID-19 pandemic has laid bare and/or worsened the pre-existing health system inequalities. Furthermore, the State in general, and the NDoH in particular, has missed an opportunity to steer an integrated, equity-oriented response to the pandemic. However, the pandemic provides the opportunity to move towards a socially just, inclusive and equitable health system. Firstly, as highlighted in our health systems framework, strong and competent leadership is critical to equity, the success of the other health system building blocks, and the achievement of population health outcomes. Drawing on the experience of the Ebola outbreak in West Africa, other scholars have underscored the importance of leadership and governance to achieving a resilient health system that is able to deal with the shocks of various health crises (Hanefeld et al., 2018). In South Africa, activists have pointed to the criticality of a capable state and public service to ensure social justice and equality (Heywood, 2021b). We recommend that the new Minister of Health should strive to revitalise and stabilise senior management in the NDoH, capable of steering and achieving the vision of a unified, responsive health system envisaged in South Africa’s Constitution (RSA, 1996) and relevant health legislation (RSA, 2004). Secondly, we propose that the pandemic provides the opportunity to invest in HRH, in line with the recommendations of the 2030 HRH Strategy (NDoH, 2020). This is because health workers are vital and the personification of the health system. Furthermore, the loss of more than 1 000 health workers due to the pandemic is detrimental to the notion of a resilient, responsive health system. Our third recommendation centres on the involvement of civil society in general, and communities in particular in the COVID-19 response, both to advance social justice, prevent corruption, and to ensure the right to health care services.

Lastly, the COVID-19 pandemic has illustrated the power of information systems, and of harnessing digital technology. In a manner similar to the selected COVID-19 statistics published on a daily basis, indicators on [in]equity by geography, public vs private sector, and race and gender, should all become a standard feature to assist us in moving towards an equitable health system. References Abdool Karim, S. S. 2020. The South African response to the pandemic. New England Journal of Medicine, 382(24):e95. Abrams, E.M., & S. J. Szefler. 2020. COVID-19 and the impact of social determinants of health. The Lancet. Respiratory Medicine, [Online] Available at: Adebisi, Y.A., A. Ekpenyong, B. Ntacyabukura, M. Lowe, N. D. Jimoh, T. O. Abdulkareem. 2020. COVID-19 Highlights the Need for Inclusive Responses to Public Health Emergencies in Africa. The American journal of tropical medicine and hygiene, 104(2):449-52. Adelekan, T., B. Mihretu, W. Mapanga, S. Nqeketo, L. Chauke, Z. Dwane. 2020. 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This article has been published by the Inclusive Society Institute

The Inclusive Society Institute (ISI) is an autonomous and independent institution that functions independently from any other entity. It is founded for the purpose of supporting and further deepening multi-party democracy. The ISI’s work is motivated by its desire to achieve non-racialism, non-sexism, social justice and cohesion, economic development and equality in South Africa, through a value system that embodies the social and national democratic principles associated with a developmental state. It recognises that a well-functioning democracy requires well-functioning political formations that are suitably equipped and capacitated. It further acknowledges that South Africa is inextricably linked to the ever transforming and interdependent global world, which necessitates international and multilateral cooperation. As such, the ISI also seeks to achieve its ideals at a global level through cooperation with like-minded parties and organs of civil society who share its basic values. In South Africa, ISI’s ideological positioning is aligned with that of the current ruling party and others in broader society with similar ideals.

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