Introduction

The South African Health Review 2022 focuses on the response, mitigation, recovery, and health-systems-strengthening strategies employed to rebuild the health system in South Africa in the wake of the COVID-19 pandemic. Information systems form a key health-systems building block. The World Health Organization (WHO) has described a well-functioning health-information system as “one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status”.1 This chapter examines the available health-information data sources in South Africa, with a particular focus on whether they have strengthened during and after the acute phase of the COVID-19 pandemic.

An upcoming book written by Dr Jonathan Kennedy, entitled Pathogenesis: How Germs Made History, examines the role of eight pathogens in shaping global history. Kennedy has been quoted as saying: “We’re living in a golden age for microbes. Population densities are increasing, people are moving more quickly around the world, the climate is changing. We’ve seen the emergence not just of COVID-19, but of HIV/AIDS, Zika, Dengue fever, SARS and Ebola. It seems now that we won’t be able to conquer infectious diseases. Rather, we’re going to have to learn to deal with the new diseases that periodically arrive to threaten us.”2 There are indications that the world is starting to ‘live with’ SARS-CoV-2, the novel coronavirus responsible for COVID-19. However, whether global and national health systems will be left more resilient, better resourced and more agile, or whether they will regress to the state of fragmentation and vulnerability exposed in 2020, remains to be seen.

The immediate signals are less than convincing. Health-information systems created under pandemic pressures are being allowed to close, are being defunded, or are simply becoming less timely and less effective. The lessons of this pandemic are at risk of being lost, even before the pandemic has formally been declared over. In a 2022 commentary, Pillay et al. pointed out that the post-COVID-19 recovery effort not only aims to ensure that services recover to “2019 levels at least”, but “to use the lessons from the COVID-19 response to radically transform the SA health system”.3

Data Sources

Box 1 shows the key new or updated sources relied on at both international and national level. Specific references and the current indicator definitions are provided in the data tables in the chapter. Many of the indicators have been normalised using population denominators. Routine data were obtained from web-based District Health Information System (WebDHIS), covering especially the 2021/22 financial year, which ran from April 2021 to March 2022. In a number of the sections below, the difference between expected and actual routine measures has been depicted graphically. The expected trends have been forecast using the Holt-Winters method.4,5

As highlighted in previous editions of the Review, caution is warranted when using data that are presented for several years. As data may be drawn from multiple sources, care should be taken in assessing trends and changes over time. Differences in methodology and data presentation may make comparisons challenging. Data from regular surveys may also not be comparable over time. In some cases, revised data for a historical time series may be released, for example with the Statistics South Africa General Household Surveys. This may result in different values being published than in previous editions of the Review. When using time-series data, the most recent revisions should be obtained from the online database and not from previous printed editions of this chapter.

Box 1.Key new or updated health data sources, 2022
International South African
  • World Health Statistics 2022
  • Human Development Report 2021/2022
  • World Malaria Report 2022
  • Global Fund Results Report 2021
  • Global Tuberculosis Report 2022
  • The State of the World’s Children 2021
  • Mental State of the World Report 2021
  • The State of Air Quality and Health Impacts in Africa 2022
  • Joint United Nations Programme on HIV and AIDS (UNAIDS) Update 2022
  • Global COVID-19 data repositories and dashboards
  • Global Cancer Incidence, Mortality and Prevalence (GLOBOCAN) 2020
  • International Diabetes Federation (IDF) Diabetes Atlas 2021
  • Web-based District Health Information System (webDHIS)
  • Tier.Net, now incorporating the Electronic TB Register
  • Electronic Drug-Resistant TB Register (EDRWeb)
  • Stats SA Mid-year population estimates 2022
  • Stats SA General Household Survey (GHS) 2021
  • Stats SA Labour Force Surveys up to the 4th quarter of 2022
  • Recorded live births 2020 & 2021
  • National Treasury health expenditure data
  • Personnel Administration System (PERSAL)
  • Thembisa v4.5 HIV and AIDS model
  • South African Community Epidemiology Network on Drug Use (SACENDU)
  • Council for Medical Schemes Annual Report 2021/22
  • Blue Drop Progress Report 2022
  • Rapid Mortality and Surveillance Report 2019 & 2020
  • Surveillance data, surveillance bulletins and other reports issued by the National Institute for Communicable Diseases (NICD)

1. Demographic indicators

There has been a lot of speculation about the impact that the COVID-19 pandemic will have on demographic trends, particularly because population ageing is driven by fertility and mortality trends. In European and other Western countries, data suggest that births had fallen sharply by the end of 2020.6 This finding is consistent with responses to pandemics in the past, where a sharp decline in births has typically been followed by gradual increases in births and then a ‘baby boom’. However, previous pandemics have also been characterised by high mortality among younger people and those of childbearing age. COVID-related deaths have been more prevalent in the older population, therefore the motivation for high birth rates to replace those who have died is not there. More than anything, the disruption of maternal health services, particularly a lack of contraception in low- and middle-income countries (LMICs) due to lockdowns, and interruptions to health services and supplies, could have inadvertently led to as many as 1.4 million unintended pregnancies.7

South Africa has the highest proportion of elderly people among countries in the African region.8 Although population ageing is still in its early stages in the country, the proportion of persons aged 60 years and older is increasing over time, as shown in the South African national population pyramid (Figure 1). This will ultimately have implications for the health system overall as it will intensify the disease burden related to multiple chronic conditions.9 Consequently, programmes and policies to address this ageing population should be prioritised as older adults have different health needs to a younger population. In addition, the country’s quadruple burden of communicable and non-communicable diseases also manifests in high levels of unhealthy ageing.9

Figure 1
Figure 1.Population pyramid by province, 2003-2030

Source: webDHIS-NDoH 2000-2030 population time series10 (received August 2020).

The total population in South Africa is estimated to have increased from 60.1 million in 2021 to 60.6 million people in 2022, with females still accounting for 51.1% of the population (Table 1). South Africa’s expected national Census could not be completed in 2021 because of the COVID-19 pandemic. The Census was postponed to 2022, and has been completed. However, the 2022 mid-year estimates do not take account of the Census data, as these figures will only be released later in 2023. The estimates are therefore continuations of the projections from the 2011 Census. As estimated, the province with the highest share of the country’s population remains Gauteng (26.6%, 16.1 million people), while the smallest share of the population is still found in the Northern Cape (2.2%, 1.31 million people). The population density has also increased in Gauteng, from 870 to 886 people per square kilometre.11 The 2022 Census may well present data showing even more marked internal migration, with populations in more rural provinces, depleted by migration, moving to the economic hubs of Gauteng and the Western Cape. Such changes in population will have major implications for the allocation of funds from the fiscus, in the form of the equitable share formula.

Table 1.Demographic indicators by province, 2020-2022
Indicator Period Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Ageing index 2021 both sexes mid-year 21,6 25,1 23,2 23,0 17,7 18,6 18,6 23,8 20,6 28,2 a
2022 both sexes mid-year 22,1 25,3 23,5 23,5 17,6 18,8 19,7 24,1 20,8 29,4 b
Annual population growth rate 2021 both sexes mid-year 1,0 a
2022 both sexes mid-year 1,1 b
Crude death rate (deaths per 1 000 population) 2020 both sexes all ages mid-year 8,7 c
2021 both sexes mid-year 11,5 a
2022 both sexes all ages mid-year 11,0 b
Live birth occurrences registered 2020 vital registration total 1 003 307 114 881 46 265 228 299 205 781 132 893 95 898 23 540 57 979 97 771 d
2021 vital registration total 1 087 526 129 381 52 260 247 378 223 712 137 780 104 061 27 980 61 605 103 368 e
Population 2021 both sexes all ages mid-year 60 142 979 6 676 590 2 932 441 15 810 388 11 513 575 5 926 724 4 743 584 1 303 047 4 122 854 7 113 776 a
both sexes all ages Stats SA 2019-30 FinYr total 60 354 419 6 544 060 3 004 609 15 874 780 11 738 948 5 959 813 4 745 703 4 176 475 1 269 273 7 040 757 f
female all ages mid-year 30 754 931 a
male all ages mid-year 29 388 047 a
2022 both sexes all ages Stats SA 2019-30 FinYr total 61 220 537 6 551 888 3 020 662 16 271 412 11 847 316 6 004 534 4 815 440 4 242 620 1 283 976 7 182 690 f
both sexes mid-year 60 604 992 6 676 691 2 921 611 16 098 571 11 538 325 5 941 439 4 720 497 1 308 734 4 186 984 7 212 142 b
female mid-year 30 980 110 b
male mid-year 29 624 882 b
Population % by province 2021 both sexes all ages mid-year 100,0 11,1 4,9 26,3 19,1 9,9 7,9 2,2 6,9 11,8 a
2022 both sexes mid-year 100,0 11,0 4,8 26,6 19,0 9,8 7,8 2,2 6,9 11,9 b
Population density 2021 mid-year 49,3 39,5 22,6 869,8 122,0 47,1 62,0 3,5 39,3 54,9 a
2022 mid-year 49,6 39,5 22,5 885,6 122,3 47,2 61,7 3,5 39,9 55,7 b
Population under 1 year 2021/22 both sexes under 1 year DHIS 1 139 382 130 901 50 371 263 761 255 744 124 972 96 828 25 739 81 115 109 951 g
Public sector dependent
(uninsured) population
2020 both sexes all ages GHS 49 798 387 5 955 518 2 501 372 11 873 601 10 005 297 5 339 978 4 145 892 1 051 559 3 450 829 5 399 356 h
both sexes all ages non med schemes 51 256 046 6 012 497 2 535 990 12 375 348 10 223 911 5 454 669 4 192 033 1 121 438 3 666 797 5 727 477 i
2021 both sexes all ages GHS 50 847 588 5 968 962 2 445 388 12 234 914 10 326 801 5 454 241 4 290 932 1 052 222 3 546 375 5 502 864 j
non med scheme 51 599 090 6 209 323 2 804 747 9 820 128 9 922 960 5 644 367 4 437 267 1 282 559 3 977 635 6 130 321 k
Total fertility rate 2022 both sexes mid-⁠year 2,3 2,9 2,3 1,8 2,5 3,0 2,3 2,6 2,5 2,0 b

Reference notes
a Stats SA MYE 2021.12
b Stats SA MYE 2022.11
c Stats SA MYE 2020.13
d Recorded Live Births 2020.14
e Recorded Live Births 2021.15
f Pop Est 2019-30.
g webDHIS.10
h Stats SA GHS 2019.16
i Medical Schemes 2020-21.17
j GHS 2021.18
k Medical Schemes 2021-22.19
Definitions

  • Population [Number]: Total number of people. Projected population figures are based on various projection models attempting to quantify the expected effects of HIV and AIDS on population growth.
  • Adolescent fertility rate (per 1 000 girls aged 15-19 years) [per 1 000 girls aged 15-19 years]: Annual number of births to women aged 15-19 years per 1 000 women in that age group. Also referred to as the age-specific fertility rate for women aged 15-19 years.
  • Ageing index [Number]: Ratio of the number of people 65+ to the number under 15 years, i.e. a value of 16 means there are 16 people aged 65 and over for every 100 under 15 years of age. Calculated as ([65+/0-14]*100).
  • Annual population growth rate [Percentage]: The rate at which the population is increasing or decreasing in a given year expressed as a percentage of the base population size. It takes into consideration all the components of population growth, namely births, deaths and migration.
  • Crude death rate (deaths per 1 000 population) [per 1 000 population]: Number of deaths in a year per 1 000 population.
  • Live birth occurrences registered [Number]: The number of live birth occurrences registered.
  • Population % by province [Percentage]: Proportion of South African population in each province (calculated from population per province and population for whole of South Africa).
  • Population density [people per km2]: The number of people per square kilometre.
  • Population under 1 year [Number]: Population under 1 year of age.
  • Public sector dependent (uninsured) population [Number]: This is an adjustment of the total population to the number assumed to be dependent on services in the public health sector based on medical scheme (health insurance) coverage. It is calculated by subtracting the number of people with medical scheme cover (determined from medical scheme membership reports, or surveys indicating percentage of population on medical schemes) from the total population.
  • Total fertility rate [Number]: The average number of children that a woman gives birth to in her lifetime, assuming that the prevailing rates remain unchanged.

COVID-19 mortality rates dramatically increased the crude death rate in South Africa within just a year from 8.7 deaths per 1000 population in 2000 to 11.5 per 1000 population in 2021. However, in 2022 the modelled crude death rate decreased slightly to 11.0, which could be signalling a recovery post-COVID.11

The Council for Medical Schemes (CMS)20 and the most recent General Household Survey18 reported on the number of medical scheme beneficiaries in 2021. According to the CMS, the number of beneficiaries covered by medical schemes increased by 0.5% between 2020 and 2021; however, overall, both estimates indicated a greater increase in the number of public sector-dependent (uninsured) population.

Table 2 and Table 3 show the webDHIS 2021/22 population estimates per 5-year age band per province, and the population estimates under 1 year of age by district, respectively. Table 4 shows the total and uninsured national, provincial and district population estimates.

Table 2.National and provincial population estimates by age group, 2022
Data Age group EC FS GP KZ LP MP NC NW WC ZA
00-⁠04 years 672 324 255 736 1 312 439 1 254 648 640 842 474 862 126 615 401 940 559 465 5 698 871
05-09 years 742 073 275 225 1 269 176 1 206 334 683 923 464 812 122 417 403 240 580 581 5 747 781
10-14 years 754 831 286 436 1 232 104 1 184 767 672 127 468 020 120 660 407 962 587 345 5 714 252
15-19 years 641 423 261 710 1 172 725 1 054 280 560 776 417 641 111 696 359 788 547 677 5 127 716
20-24 years 446 362 226 710 1 361 696 942 756 438 857 379 056 95 907 308 020 544 816 4 744 180
25-29 years 448 862 234 559 1 676 705 1 007 870 459 359 415 475 102 623 340 336 627 099 5 312 888
30-34 years 509 302 255 819 1 765 548 1 037 819 503 828 449 514 115 352 383 469 684 309 5 704 960
35-39 years 477 079 237 118 1 551 317 922 228 467 497 415 064 109 589 359 327 651 745 5 190 964
40-44 years 376 074 185 817 1 204 748 691 506 373 113 318 885 86 589 288 422 524 513 4 049 667
45-49 years 316 706 154 270 958 401 556 498 302 871 250 403 70 290 234 740 437 730 3 281 909
50-54 years 272 493 133 078 766 418 444 613 242 391 199 836 59 743 192 645 384 670 2 695 887
55-59 years 247 062 115 550 631 025 384 910 207 573 166 681 50 210 162 607 329 427 2 295 045
60-64 years 228 979 96 863 518 950 322 761 170 566 129 856 42 317 134 595 268 461 1 913 348
65-69 years 189 870 78 534 395 579 254 007 139 852 101 388 34 838 100 365 201 474 1 495 907
70-74 years 140 214 57 013 274 282 192 803 104 293 71 045 25 762 67 595 144 581 1 077 588
75-79 years 98 996 35 341 164 093 123 743 65 202 41 869 17 194 44 547 94 417 685 402
80+ years 148 765 30 699 106 946 101 622 91 372 50 653 19 006 41 681 75 211 665 955
Total 6 711 415 2 920 478 16 362 152 11 683 165 6 124 442 4 815 060 1 310 808 4 231 279 7 243 521 61 402 320

Source: webDHIS Pop Est 2000-30.

Table 3.Population estimates under 1 year of age by district, 2022/23
Province District Female under
1 year
Male under
1 year
Population
under 1
EC BUF: Buffalo City MM 5 382 5 523 10 905
DC10: Sarah Baartman DM 3 587 3 622 7 209
DC12 : Amathole DM 7 308 7 535 14 843
DC13: C Hani DM 6 628 6 815 13 443
DC14: Joe Gqabi DM 3 081 3 133 6 214
DC15: OR Tambo DM 19 849 20 403 40 252
DC44: A Nzo DM 10 992 11 181 22 173
NMA : N Mandela Bay MM 8 078 8 095 16 173
FS DC16: Xhariep DM 1 268 1 287 2 555
DC18: Lejweleputswa DM 5 325 5 328 10 653
DC19: T Mofutsanyana DM 7 232 7 336 14 568
DC20: Fezile Dabi DM 4 021 4 078 8 099
MAN : Mangaung MM 7 092 7 389 14 481
GP DC42: Sedibeng DM 7 298 7 556 14 854
DC48: West Rand DM 7 410 7 706 15 116
EKU : City of Ekurhuleni MM 34 209 34 970 69 179
JHB : Johannesburg MM 48 794 49 799 98 593
TSH : Tshwane MM 31 681 32 573 64 254
KZ DC21: Ugu DM 9 322 9 446 18 768
DC22: uMgungundlovu DM 11 349 11 575 22 924
DC23: uThukela DM 8 324 8 626 16 950
DC24: uMzinyathi DM 7 835 8 165 16 000
DC25: Amajuba DM 6 343 6 555 12 898
DC26: Zululand DM 11 007 11 400 22 407
DC27: uMkhanyakude DM 8 805 8 941 17 746
DC28: King Cetshwayo DM 11 216 11 552 22 768
DC29: iLembe DM 7 699 7 856 15 555
DC43: Harry Gwala DM 6 243 6 374 12 617
ETH : eThekwini MM 37 009 38 396 75 405
LP DC33: Mopani DM 12 416 12 951 25 367
DC34: Vhembe DM 14 902 15 513 30 415
DC35: Capricorn DM 13 361 13 909 27 270
DC36: Waterberg DM 6 623 6 863 13 486
DC47: Sekhukhune DM 14 107 14 653 28 760
MP DC30: G Sibande DM 12 643 12 883 25 526
DC31: Nkangala DM 14 498 14 931 29 429
DC32: Ehlanzeni DM 19 827 20 302 40 129
NC DC6 : Namakwa DM 928 916 1 844
DC7 : Pixley Ka Seme DM 2 090 2 141 4 231
DC8 : ZF Mgcawu DM 2 548 2 524 5 072
DC9 : Frances Baard DM 3 963 4 083 8 046
DC45: JT Gaetsewe DM 3 025 3 062 6 087
NW DC37: Bojanala Platinum DM 17 818 18 060 35 878
DC38: NM Molema DM 8 620 8 682 17 302
DC39: RS Mompati DM 5 929 6 105 12 034
DC40: Dr K Kaunda DM 7 683 7 754 15 437
WC CPT : Cape Town MM 34 900 36 470 71 370
DC1 : West Coast DM 3 847 3 929 7 776
DC2 : Cape Winelands DM 7 848 8 167 16 015
DC3 : Overberg DM 2 583 2 749 5 332
DC4 : Garden Route DM 4 989 5 202 10 191
DC5 : Central Karoo DM 578 594 1 172
Total 560 113 575 658 1 135 771

Source: webDHIS10

Table 4.Population estimates: modelled estimates for medical schemes coverage and uninsured population national, provincial and district, 2019-2023
Total Population (DHIS Pop Est 2000-30) Med schemes coverage (Insight Actuaries model 2019) Uninsured Calculated
2019 2020 2021 2022 2023 2018 2019 2020 2021 2022 2023
Country ZA 58 979 654 59 797 656 60 604 086 61 402 320 62 197 960 15,4 49 896 787 50 588 817 51 271 057 51 946 363 52 619 474
Province EC 6 711 899 6 713 318 6 714 789 6 711 415 6 709 060 9,8 6 054 133 6 055 413 6 056 740 6 053 696 6 051 572
FS 2 890 007 2 900 278 2 910 130 2 920 478 2 930 982 13,5 2 499 856 2 508 740 2 517 262 2 526 213 2 535 299
GP 15 268 630 15 635 579 15 997 809 16 362 152 16 723 636 24,6 11 512 547 11 789 227 12 062 348 12 337 063 12 609 622
KZ 11 319 610 11 441 785 11 563 182 11 683 165 11 801 471 11,2 10 051 814 10 160 305 10 268 106 10 374 651 10 479 706
LP 5 993 527 6 039 032 6 084 467 6 124 442 6 165 877 7,2 5 561 993 5 604 222 5 646 385 5 683 482 5 721 934
MP 4 609 880 4 680 103 4 748 543 4 815 060 4 880 047 12,5 4 033 645 4 095 090 4 154 975 4 213 178 4 270 041
NC 1 267 621 1 282 813 1 297 034 1 310 808 1 324 275 15,1 1 076 210 1 089 108 1 101 182 1 112 876 1 124 309
NW 4 043 350 4 107 283 4 169 094 4 231 279 4 293 016 11,9 3 562 191 3 618 516 3 672 972 3 727 757 3 782 147
WC 6 875 130 6 997 465 7 119 038 7 243 521 7 369 596 20,1 5 493 229 5 590 975 5 688 111 5 787 573 5 888 307
District BUF 799 711 798 388 796 759 794 314 791 614 22,4 620 576 619 549 618 285 616 388 614 292
CPT 4 510 747 4 598 783 4 686 530 4 776 492 4 867 548 22,2 3 509 361 3 577 853 3 646 120 3 716 111 3 786 952
DC1 455 676 463 390 471 043 478 958 487 115 17,3 376 844 383 224 389 553 396 098 402 844
DC2 925 999 942 232 958 398 974 747 991 117 16,4 774 135 787 706 801 221 814 888 828 574
DC3 294 278 299 764 305 203 310 662 316 173 16,4 246 016 250 603 §§ 259 713 264 321
DC4 614 134 618 954 623 516 628 217 633 013 16,5 512 802 516 827 520 636 524 561 528 566
DC5 74 296 74 342 74 348 74 445 74 630 12,5 65 009 65 049 65 055 65 139 65 301
DC6 113 937 114 035 114 077 114 245 114 367 17,5 93 998 94 079 94 114 94 252 94 353
DC7 204 290 206 326 208 167 209 912 211 609 13,1 177 528 179 297 180 897 182 414 183 888
DC8 273 681 278 104 282 362 286 400 290 296 15,8 230 439 234 164 237 749 241 149 244 429
DC9 410 232 414 190 417 771 421 181 424 540 15,7 345 826 349 162 352 181 355 056 357 887
DC10 478 448 480 810 483 024 484 665 486 523 8,8 436 345 438 499 440 518 442 014 443 709
DC12 804 398 795 781 787 417 778 884 770 438 4,3 769 809 761 562 753 558 745 392 737 309
DC13 741 095 731 081 721 434 712 004 702 218 4,9 704 781 695 258 686 084 677 116 667 809
DC14 344 401 342 580 340 685 338 445 336 219 5,0 327 181 325 451 323 651 321 523 319 408
DC15 1 508 997 1 524 972 1 541 080 1 555 812 1 571 532 4,2 1 445 619 1 460 923 1 476 355 1 490 468 1 505 528
DC16 126 989 127 071 127 119 127 251 127 471 10,5 113 655 113 729 113 772 113 890 114 087
DC18 642 629 643 043 643 503 644 397 645 123 12,0 565 514 565 878 566 283 567 069 567 708
DC19 755 188 755 842 756 396 757 178 758 118 9,2 685 711 686 305 686 808 687 518 688 371
DC20 504 155 505 057 505 879 506 744 507 595 13,2 437 607 438 389 439 103 439 854 440 592
DC21 804 993 816 195 827 384 838 645 850 311 7,1 747 838 758 245 768 640 779 101 789 939
DC22 1 123 554 1 137 023 1 150 285 1 163 352 1 177 092 11,0 999 963 1 011 950 1 023 754 1 035 383 1 047 612
DC23 704 433 706 771 708 994 711 516 714 070 6,4 659 349 661 538 663 618 665 979 668 370
DC24 557 752 563 568 569 454 575 760 582 409 5,4 527 633 533 135 538 703 544 669 550 959
DC25 558 701 565 495 572 008 577 873 583 415 7,4 517 357 523 648 529 679 535 110 540 242
DC26 858 938 863 111 867 237 872 128 877 196 5,2 814 273 818 229 822 141 826 777 831 582
DC27 671 378 676 068 680 655 685 592 690 192 5,0 637 809 642 265 646 622 651 312 655 682
DC28 960 065 964 828 969 742 975 004 980 188 8,7 876 539 880 888 885 374 890 179 894 912
DC29 671 846 680 361 688 960 696 590 703 372 8,6 614 067 621 850 629 709 636 683 642 882
DC30 1 218 483 1 240 644 1 262 612 1 283 719 1 304 284 13,1 1 058 862 1 078 120 1 097 210 1 115 552 1 133 423
DC31 1 580 378 1 613 205 1 645 648 1 677 409 1 708 843 14,8 1 346 482 1 374 451 1 402 092 1 429 152 1 455 934
DC32 1 811 019 1 826 254 1 840 283 1 853 932 1 866 920 10,2 1 626 295 1 639 976 1 652 574 1 664 831 1 676 494
DC33 1 209 120 1 218 016 1 226 939 1 234 474 1 241 931 6,8 1 126 900 1 135 191 1 143 507 1 150 530 1 157 480
DC34 1 460 085 1 474 045 1 488 161 1 501 251 1 514 770 6,6 1 363 719 1 376 758 1 389 942 1 402 168 1 414 795
DC35 1 344 562 1 349 214 1 353 845 1 357 666 1 361 654 8,3 1 232 963 1 237 229 1 241 476 1 244 980 1 248 637
DC36 763 309 769 853 776 172 781 264 786 231 9,1 693 848 699 796 705 540 710 169 714 684
DC37 1 884 307 1 929 057 1 972 917 2 015 765 2 058 230 14,0 1 620 504 1 658 989 1 696 709 1 733 558 1 770 078
DC38 901 629 906 601 910 841 916 394 922 575 9,7 814 171 818 661 822 489 827 504 833 085
DC39 470 086 471 910 473 588 475 637 477 280 7,3 435 770 437 461 439 016 440 915 442 439
DC40 787 328 799 715 811 748 823 483 834 931 12,8 686 550 697 351 707 844 718 077 728 060
DC42 960 427 963 811 966 230 968 999 972 188 20,8 760 658 763 338 765 254 767 447 769 973
DC43 503 616 506 908 510 113 513 778 517 618 5,6 475 414 478 521 481 547 485 006 488 631
DC44 826 587 828 210 830 067 831 112 832 500 3,8 795 177 796 738 798 524 799 530 800 865
DC45 265 481 270 158 274 657 279 070 283 463 13,9 228 579 232 606 236 480 240 279 244 062
DC47 1 216 451 1 227 904 1 239 350 1 249 787 1 261 291 5,6 1 148 330 1 159 141 1 169 946 1 179 799 1 190 659
DC48 943 535 956 893 969 545 982 753 996 636 24,1 716 143 726 282 735 885 745 910 756 447
EKU 3 910 546 3 996 528 4 080 699 4 165 110 4 250 640 23,8 2 979 836 3 045 354 3 109 493 3 173 814 3 238 988
ETH 3 904 334 3 961 457 4 018 350 4 072 927 4 125 608 18,9 3 166 415 3 212 742 3 258 882 3 303 144 3 345 868
JHB 5 781 281 5 951 077 6 121 322 6 295 072 6 465 812 22,2 4 497 837 4 629 938 4 762 389 4 897 566 5 030 402
MAN 861 046 869 265 877 233 884 908 892 675 20,0 688 837 695 412 701 786 707 926 714 140
NMA 1 208 262 1 211 496 1 214 323 1 216 179 1 218 016 20,4 961 777 964 351 966 601 968 078 969 541
TSH 3 672 841 3 767 270 3 860 013 3 950 218 4 038 360 30,6 2 548 952 2 614 485 2 678 849 2 741 451 2 802 622

2. Socio-economic and environmental risk factors

As expected, COVID-19 exacerbated pre-existing poverty and inequalities on a global scale. As much as it was a health crisis, it also disrupted livelihoods and exposed societal weaknesses, which ultimately intensified the impact of the pandemic. As one of the most unequal countries in the world, South Africa experienced a widening gap between the rich and the poor during the pandemic. The poor were hardest hit after many lost their jobs and had their income reduced. From an economic perspective, the pandemic led to a sharp 7% decline in the country’s Gross Domestic Product (GDP) in 2020, and a rise in unemployment rates. When comparing unemployment rates in the fourth quarters of the period from 2020 to 2022, unemployment was highest in 2021 at 35.3%. Unemployment does appear to be easing, as total employment increased by 1.4 million people between the fourth quarters of 2021 and 2022.21

An interesting phenomenon of the COVID-19 lockdowns was how blue skies appeared in some of the world’s most polluted areas due to reduced industrial activity and fewer cars on the roads.22 This was a temporary fix, however, as air pollution continues to be one of the leading and most direct environmental threats to human health. Pollution is linked to increased susceptibility to respiratory infections, including COVID-19. Furthermore, long-term exposures to air pollution have been linked to increased risk of illness and death from chronic diseases such as stroke, lung cancer, ischaemic heart disease, chronic obstructive pulmonary disease (COPD), type 2 diabetes23,24 and even stillbirths.25 The State of Air Quality and Health Impacts in Africa report summarised data on air pollution exposures and associated health impacts in Africa using data from the Global Burden of Disease (GBD) project. South Africa has some of the highest levels of air pollution in the world, and was one of the five countries whose data were analysed in the report, in addition to Egypt, Ghana, Kenya and the Democratic Republic of Congo. The report estimated that in 2019, the death rate linked to household and ambient air pollution in South Africa was 44.6 (35.4-53.8) per 100 000 people per year. Figure 2 shows the percentage of cause-specific deaths linked to air pollution, with estimates being highest for COPD and diabetes in South Africa.23 The latest data from the Air Quality Life Index (AQLI) illustrates that permanently reducing global air pollution to meet the WHO’s guideline would add 2.2 years onto average life expectancy globally, and 1.5 years for South Africa specifically. However, in order for that to happen, strategies that reduce exposure and vulnerability to air pollution need to be developed to reduce the burden on public health.22,24

Figure 2
Figure 2.Percentage of cause-specific deaths linked to air pollution in five focus countries in Africa, 2019

Source: SoGA-Africa.23

The 2021/22 Human Development Report developed a COVID-19-adjusted human development index (HDI) quantifying the complexity of the crisis from a multi-dimensional view.26 Interestingly, South Africa’s human development rank (HDR) improved from 115 in 2019 to 102 in 2020, while the HDI remained relatively constant in 2019 (0.736), 2020 (0.727), and 2021 (0.713), as illustrated in Table 5. The countries with the highest HDI ranking were Norway, Iceland and Switzerland. Coincidentally, these three countries were also ranked among the top 10 happiest in the world according to the 2023 World Happiness Report.27 South Africa was ranked 85th among 109 countries between 2020 and 2022. The happiness scores were determined based on six key variables: GDP per capita, social support, healthy life expectancy, freedom to make life choices, generosity, and freedom from corruption. One of the central findings of the report was that the quality of social context, particularly the extent to which people trusted the government and the extent to which they trusted the compassion of their peers, supported their happiness before and during the pandemic, and likely after the pandemic too.

Table 5.Socio-economic indicators by province, 2019-2022
Indicator Period Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Age-standardized mortality rate attributed to household and ambient air pollution (per 100 000 population) 2019 WHO 74,9 a
WHO COPD 5,2 a
WHO Ischeamic heart disease 15,3 a
WHO Lower respiratory infections 20,7 a
WHO Stroke 10,2 a
WHO Trachea, bronchus, lung cancers 2,9 a
SOGA 44,6 b
Drinking Water System (Blue Drop) Performance Rating 2021 Blue Drop Low risk 48,0 51,9 37,7 82,8 48,0 35,6 58,9 46,7 12,2 85,0 c
Blue Drop Medium risk 18,0 23,5 15,6 10,3 18,1 18,4 20,5 22,1 17,1 7,9 c
Blue Drop High risk 11,0 11,2 19,5 3,4 7,4 21,8 8,0 11,6 17,7 3,1 c
Blue Drop Critical risk 23,0 13,4 27,3 3,4 26,5 24,1 12,5 19,6 53,0 3,9 c
Education level: percentage of population with no schooling 2021 both sexes 20 years and older GHS 3,2 4,6 2,6 1,0 4,4 7,1 6,3 3,2 3,9 0,7 d
Human development index (high value = best) 2019 both sexes all ages HDR 0,71 e
2020 both sexes all ages HDR 0,73 f
2021 both sexes all ages HDR 0,7 f
Human development index rank (1= best) 2019 both sexes all ages HDR 115 e
2020 both sexes all ages HDR 102 f
Percentage of households by type of housing 2021 both sexes GHS Formal 83,6 72,4 82,6 81,6 85,7 96,3 89,8 86,8 80,5 82,2 d
both sexes GHS Informal 11,7 5,4 15,4 17,0 5,0 2,9 7,1 12,3 19,1 17,3 d
both sexes GHS Traditional 4,2 21,6 2,0 0,1 9,3 0,7 3,1 0,5 0,4 0,1 d
Percentage of households using electricity for cooking 2021 GHS 77,7 77,7 87,2 77,4 82,3 64,5 71,4 83,0 78,8 80,5 d
Percentage of households with access to improved sanitation 2019 GHS 82,1 87,6 82,3 90,0 80,9 63,4 63,7 83,9 68,8 94,5 g
2020 GHS 83,2 92,7 85,8 90,5 81,2 58,7 64,4 86,9 78,3 93,9 d
2021 GHS 84,1 91,7 86,3 91,8 84,5 58,5 63,2 87,4 77,8 94,8 d
Percentage of households with access to piped water 2020 GHS 89,1 72,1 93,3 98,0 86,9 71,3 87,9 91,8 87,3 98,5 d
2021 GHS 88,7 71,0 93,6 98,4 87,0 69,4 86,2 90,9 83,4 99,4 d
Percentage of households with telephone (telephone in dwelling or cell phone) 2021 GHS 97,8 97,4 98,0 98,4 96,7 95,4 98,9 97,6 99,2 98,5 d
Percentage of population with primary reliance on clean fuels 2019 WHO 86,0 h
2020 WHO 87,0 i
Unemployment rate (official definition) 2020 Q4 both sexes 15-64 years LFS 32,5 47,9 33,4 34,1 29,6 27,3 33,0 28,7 33,3 22,5 j
2021 Q4 both sexes 15-64 years LFS 35,3 45,0 36,7 36,6 32,4 33,9 39,7 25,0 33,8 28,0 k
2022 Q4 both sexes 15-64 years LFS 32,7 42,1 22,1 34,0 31,4 31,8 36,1 22,1 37,0 22,5 l
Air pollution level in cities (particulate matter [PM]) 2020 AQLI PM2.5 20,3 m
Wastewater systems (Green Drop) Performance Rating 2021 Green Drop 37,0 51,0 26,0 68,0 68,0 29,0 49,0 41,0 30,0 84,0 n
Green Drop Critical risk 39,0 39,0 67,0 15,0 14,0 78,0 43,0 76,0 69,0 11,0 n

Reference notes
a Global Health Observatory.28
b SOGA Africa 2021.23
c Blue Drop 2022.29
d GHS 2021.18
e HDR 2020.30
f HDR 2022.26
g Stats SA GHS 2019.16
h World Health Statistics 2021.31
i World Health Statistics 2022.32
j Labour Force Survey Q4 2020.33
k Labour Force Survey Q4 2021.34
l Labour Force Survey Q4 2022.21
m Air Quality Life Index 2022.22
n Green Drop 2022.35
Definitions

  • Drinking Water System (Blue Drop) Performance Rating [Percentage]: Composite score measuring compliance of water suppliers with water quality management requirements. Includes microbiological, chemical and physical compliance criteria.
  • Education level: percentage of population with no schooling [Percentage]: Percentage of people in a given age group who have received a particular level of education.
  • Human development index (high value = best) [Number]: The HDI is a summary measure of human development. It measures the average achievements in a country in three basic dimensions of human development:
  • Human development index rank (1 = best) [Number]: Rank from 1 to end given to each country according to value of HDI.
  • Percentage of households by type of housing [Percentage]: Percentage of households that are categorised as formal, informal, traditional or other.
  • Percentage of households using electricity for cooking [Percentage]: Percentage of households using electricity as their main energy source for cooking.
  • Percentage of households with access to improved sanitation [Percentage]: Percentage of households using improved sanitation facilities (including flush to piped sewer system, flush to septic tank, flush/pour flush to pit, flush/pour flush to elsewhere).
  • Percentage of households with access to piped water [Percentage]: Includes households with piped water in dwelling, piped water inside yard or piped water on a community stand (<200m away or further).
  • Percentage of households with telephone (telephone in dwelling or cell phone) [Percentage]: Percentage of households with a telephone in the dwelling or a cellular telephone.
  • Percentage of population with primary reliance on clean fuels [Percentage]: Percentage of population with primary reliance on clean fuels.
  • Unemployment rate (official definition) [Percentage]: The official definition of the unemployed is that they are those people within the economically active population (aged 15-65) who:
    (a) did not have a job or business during the 7 days prior to the interview,
    (b) want to work and are available to work within two weeks of the interview, and
    (c) have taken active steps to look for work or to start some form of self-employment in the 4 weeks prior to the interview.
  • Wastewater systems (Green Drop) Performance Rating [Percentage]: Composite score measuring compliance of wastewater management requirements.

In 2022, the Department of Water and Sanitation released the first Blue Drop Progress Report since 2015, reporting on the current status and risk trends of municipal potable water-treatment facilities.29 A total of 144 water service authorities, comprising 1 186 water-supply systems in South Africa, were assessed to calculate the Blue Drop Risk Rating (BDRR). Overall, the National BDRR profile for the country was summarised as follows:

  • 48% of water-supply systems were found to be in the low-risk category,

  • 18% were in the medium-risk category,

  • 11% were in the high-risk category, and

  • 23% were in the critical-risk category.

The Green Drop Report, which was also released in 2022, focused on the state of wastewater treatment plants.35 The report covered audits of 995 wastewater networks and treatment works, operated by 144 water-service authorities (850 systems), 12 Department of Public Works operations (115 systems), and five private- and state-owned organisations (30 systems). Only 23 systems scored 90% or more, with most rural municipalities struggling to score more than 50%. A total of 334 (39%) of the municipal wastewater systems were identified to be in a critical state in 2021. Overall, the assessed risk deteriorated between 2013 and 2021.

Safe and readily available water is important for public health as contaminated water and poor sanitation are linked to transmission of gastrointestinal diseases such as cholera. During COVID-19, access to clean water was considered critical in the prevention of transmission. Water assessments should be conducted more frequently to ensure that systems and strategies are in place to reduce the risk to the people supplied by these two critical systems.

3. Disability

South Africans with disabilities were greatly and uniquely affected by COVID-19. They were at greater risk of poor outcomes from the disease; lockdown periods reduced their access to routine health care and rehabilitation services; and efforts to mitigate the pandemic led to adverse social impacts in this group.36 This situation was not unique to South Africa. The International Disability Alliance urged policy makers to make those living with disabilities a priority during the vaccination roll-out to prevent them from being left further behind, having to struggle with disproportionate loss of lives and livelihoods, inability to access healthcare services, and disconnection from the general population.37 In November 2022, the National Department of Women, Youth and Persons with Disabilities released a report on the impact of COVID-19 on persons with disabilities in South Africa, which stated that the rights of many persons with disabilities were either denied or limited during the pandemic, even though there were a few positive stories and experiences shared by some. With regard to health-related issues, the report highlighted that persons living with disabilities experienced difficulties with adhering to the mandatory COVID-19 guidelines such as social distancing and wearing of personal protective equipment (PPE), and accessing health care, therapy, medication, specialist care and assistive devices. Figure 3 shows that provision of assistive devices dropped substantially in 2020.38

Figure 3
Figure 3.Number of assistive devices required per province, 2017/18 - 2021/22

Source: webDHIS.10

It has been found that people with disabilities are more likely to be older, female, poorer, and to have additional comorbidities than their able peers.36 As of 2021, more women were classified as disabled (4.9%) than men (4.1%).18 Living with disabilities leads to challenges in all aspects of life, including access to healthcare services, aids or devices, medication and support (for example, when caregivers are infected with COVID-19). These impacts are exacerbated in local and middle-income countries (LMICs), which often face additional challenges of corruption, political instability, lack of suitable transportation, and a general negative attitude to those living with disability, and to disability overall.39 Table 6 shows how the provision of assistive devices slowed down in 2020/21, particularly for spectacles. However, there was a steady improvement in the 2021/22 financial year, in some instances even returning to pre-pandemic levels.

Table 6.Disability indicators by province, 2019/20 - 2021/22
Indicator Period        Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Cataract surgery - total 2019/20 both sexes all ages DHIS 58 808 2 971 7 592 12 454 19 781 3 483 1 730 776 2 440 7 581 a
2020/21 both sexes all ages DHIS 19 108 362 313 4 339 9 660 1 427 601 166 2 240 a
2021⁠⁠⁠/⁠⁠22 both sexes all ages DHIS 38 388 1 552 1 880 8 385 16 767 3 063 463 1 155 5 123 a
Cataract surgery rate 2019/20 both sexes DHIS 1 022,0 404,9 2 628,0 879,1 1 754,0 586,5 380,9 630,8 606,4 1 133,0 a
2020/21 both sexes DHIS 262,9 48,9 106,0 296,3 819,1 232,8 0,0 488,3 41,1 333,4 a
2021/22 both sexes DHIS 633,4 231,1 646,0 524,1 1 450,0 503,4 357,0 277,0 719,6 a
Hearing aid issued - total 2019/20 both sexes all ages DHIS 19 890 2 223 680 6 418 3 663 641 1 630 430 1 314 2 891 a
2020/21 both sexes all ages DHIS 11 489 1 281 270 2 794 3 102 373 1 041 164 916 1 548 a
2021/22 both sexes all ages DHIS 17 794 1 576 437 5 924 4 374 467 1 288 218 1 187 2 323 a
Hearing aid issued adult 19 years and older 2020/21 both sexes DHIS 9 531 1 093 160 2 463 2 433 293 941 118 722 1 308 a
2021/22 both sexes DHIS 14 481 1 222 251 5 130 3 249 376 1 107 155 1 042 1 949 a
Hearing aid issued adult 19 years and older rate 2020/21 both sexes DHIS 41,9 72,2 124,0 80,9 47,6 36,9 42,6 52,0 8,6 99,2 a
2021/22 both sexes DHIS 71,2 71,4 137,2 78,5 53,5 31,4 68,1 54,0 103,4 113,8 a
Hearing aid issued child 0-18 years 2020/21 both sexes DHIS 1 958 188 110 331 669 80 100 46 194 240 a
2021/22 both sexes DHIS 3 313 354 186 794 1 125 91 181 63 145 374 a
Hearing aid issued child 0-18 years rate 2020/21 both sexes DHIS 66,8 53,6 323,5 73,9 76,7 58,8 45,7 107,0 37,0 79,2 a
2021/22 both sexes DHIS 77,6 64,8 357,7 79,3 63,1 51,7 88,7 76,8 109,8 127,6 a
Hearing aid required - total 2019/20 both sexes all ages DHIS 30 943 3 754 730 7 988 6 827 2 884 3 301 432 1 715 3 312 a
2020/21 both sexes DHIS 25 672 1 864 163 3 493 5 985 931 2 429 270 8 915 1 622 a
2021/22 both sexes all ages DHIS 24 606 2 258 235 7 538 7 860 1 372 1 829 369 1 140 2 005 a
Hearing aid required adult 19 years and older 2020/21 both sexes DHIS 22 741 1 513 129 3 045 5 113 795 2 210 227 8 390 1 319 a
2021/22 both sexes DHIS 20 338 1 712 183 6 537 6 078 1 196 1 625 287 1 008 1 712 a
Hearing aid required child 0-18 years 2020/21 both sexes DHIS 2 931 351 34 448 872 136 219 43 525 303 a
2021/22 both sexes DHIS 4 268 546 52 1 001 1 782 176 204 82 132 293 a
Hearing aids issued rate 2019/20 both sexes all ages DHIS 64,3 59,2 93,2 80,3 53,7 22,2 49,4 99,5 76,6 87,3 a
2020/21 both sexes DHIS 44,8 68,7 165,6 80,0 51,8 40,1 42,9 60,7 10,3 95,4 a
2021/22 both sexes DHIS 72,3 69,8 186,0 78,6 55,6 34,0 70,4 59,1 104,1 115,9 a
Prevalence of disability 2021 both sexes 5+ years GHS 4,5 4,8 4,9 3,1 5,5 5,2 3,8 7,1 4,6 4,9 b
female 5+ years GHS 4,9 b
male 5+ years GHS 4,1 b
Spectacles issued - total 2019/20 both sexes all ages DHIS 93 086 8 964 727 20 818 25 229 3 179 3 247 1 852 2 077 26 993 a
2020/21 both sexes all ages DHIS 62 739 3 500 394 11 845 23 026 4 363 2 547 1 201 395 15 468 a
2021/22 both sexes all ages DHIS 112 249 4 206 9 573 22 339 29 958 4 462 3 970 1 413 1 710 34 618 a
Spectacles issued rate 2019/20 both sexes all ages DHIS 56,0 57,3 44,3 63,0 55,4 18,2 63,7 65,6 38,6 68,3 a
2020/21 both sexes all ages DHIS 60,2 44,5 61,8 46,3 68,7 55,4 52,7 73,3 46,1 72,3 a
2021/22 both sexes all ages DHIS 68,5 46,8 109,1 64,3 62,7 40,7 77,3 67,9 98,2 79,2 a
Spectacles issued to an adult - total 2020/21 both sexes DHIS 56 913 3 340 361 10 561 19 652 4 034 2 334 1 173 374 15 084 a
2021/22 both sexes DHIS 98 553 3 844 9 172 18 934 25 338 3 968 3 311 1 357 1 522 31 107 a
Spectacles issued to an adult rate 2020/21 both sexes DHIS 61,5 56,3 71,8 44,7 70,7 56,9 50,9 74,0 49,1 73,0 a
2021/22 both sexes DHIS 69,9 49,3 134,8 65,6 63,1 41,5 78,8 67,6 98,0 77,7 a
Spectacles issued to child - total 2020/21 both sexes DHIS 5 826 160 33 1 284 3 374 329 213 28 21 384 a
2021/22 both sexes DHIS 13 696 362 401 3 405 4 620 494 659 56 188 3 511 a
Spectacles issued to child rate 2020/21 both sexes DHIS 49,7 8,3 24,4 64,6 58,8 41,4 84,2 52,8 22,1 51,8 a
2021/22 both sexes DHIS 59,6 30,4 20,3 57,8 60,4 35,1 70,6 76,7 99,5 95,9 a
Spectacles required - total 2019/20 both sexes all ages DHIS 166 220 15 637 1 641 33 068 45 567 17 467 5 101 2 823 5 379 39 537 a
2020/21 both sexes all ages DHIS 104 250 7 869 638 25 611 33 518 7 882 4 837 1 638 857 21 400 a
2021/22 both sexes all ages DHIS 163 908 8 980 8 778 34 741 47 778 10 965 5 137 2 080 1 742 43 707 a
Spectacles required by an adult - total 2020/21 both sexes DHIS 92 518 5 932 503 23 622 27 784 7 088 4 584 1 585 762 20 658 a
2021/22 both sexes DHIS 140 935 7 790 6 806 28 845 40 128 9 557 4 203 2 007 1 553 40 046 a
Spectacles required by child - total 2020/21 both sexes DHIS 11 732 1 937 135 1 989 5 734 794 253 53 95 742 a
2021/22 both sexes DHIS 22 973 1 190 1 972 5 896 7 650 1 408 934 73 189 3 661 a
Wheelchair issued - total 2019/20 both sexes all ages DHIS 23 611 1 792 1 271 4 643 4 155 2 614 1 720 241 1 183 5 992 a
2020/21 both sexes all ages DHIS 20 646 2 351 1 123 3 149 4 346 2 041 1 776 56 1 066 4 738 a
2021/22 both sexes all ages DHIS 23 653 2 298 1 242 4 706 4 537 2 076 1 651 309 1 176 5 658 a
Wheelchair issued adult 19 years and older 2020/21 both sexes DHIS 18 035 2 031 905 2 758 3 710 1 826 1 543 45 953 4 264 a
2021/22 both sexes DHIS 19 956 1 719 1 029 4 066 3 676 1 872 1 374 246 1 025 4 949 a
Wheelchair issued adult 19 years and older rate 2020/21 both sexes DHIS 62,10 39,10 87,40 91,50 76,90 81,30 94,40 0,81 65,60 104,00 a
2021/22 both sexes DHIS 61,50 31,30 88,60 86,80 73,00 62,10 78,90 5,00 72,90 99,90 a
Wheelchair issued child 0-18 years 2020/21 both sexes DHIS 2 611 320 218 391 636 215 233 11 113 474 a
2021/22 both sexes DHIS 3 697 579 213 640 861 204 277 63 151 709 a
Wheelchair issued child 0-18 years rate 2020/21 both sexes DHIS 58,9 41,9 137,1 74,5 52,2 86,0 54,8 1,8 87,6 136,2 a
2021/22 both sexes DHIS 62,5 62,1 61,7 70,0 67,2 54,3 66,0 11,6 101,3 74,6 a
Wheelchair required - total 2019/20 both sexes all ages DHIS 38 898 7 725 1 763 5 288 7 777 3 945 3 590 626 1 855 6 329 a
2020/21 both sexes DHIS 33 485 5 957 1 195 3 539 6 043 2 496 2 060 6 167 1 581 4 447 a
2021/22 both sexes all ages DHIS 38 366 6 433 1 506 5 599 6 318 3 389 2 162 5 502 1 555 5 902 a
Wheelchair required adult 19 years and older 2020/21 both sexes DHIS 29 052 5 193 1 036 3 014 4 825 2 246 1 635 5 552 1 452 4 099 a
2021/22 both sexes DHIS 32 452 5 500 1 161 4 685 5 036 3 013 1 742 4 957 1 406 4 952 a
Wheelchair required child 0-18 years 2020/21 both sexes DHIS 4 433 764 159 525 1 218 250 425 615 129 348 a
2021/22 both sexes DHIS 5 914 933 345 914 1 282 376 420 545 149 950 a
Wheelchairs issued rate 2019/20 both sexes all ages DHIS 60,7 23,2 72,1 87,8 53,4 66,3 47,9 38,5 63,8 94,7 a
2020/21 both sexes DHIS 61,7 39,5 94,0 89,0 71,9 81,8 86,2 0,9 67,4 106,5 a
2021/22 both sexes DHIS 61,7 35,7 82,5 84,1 71,8 61,3 76,4 5,6 75,6 95,9 a

Reference notes
a webDHIS.10
b GHS 2021.18
Definitions

  • Cataract surgery - total [Number]: Number of eyes on which cataract surgery was performed.
  • Hearing aid issued - total [Number]: All hearing aids issued to patients.
  • Hearing aid issued adult 19 years and older [Number]: All hearing aids issued to adults 19 years and older.
  • Hearing aid issued child 0-18 years [Number]: All hearing aids issued to children 0 to 18 years.
  • Hearing aid required - total [Number]: All hearing aids required.
  • Hearing aid required adult 19 years and older [Number]: All hearing aids required by adults 19 years and older.
  • Hearing aid required child 0-18 years [Number]: All hearing aids required by children 0-18 years.
  • Spectacles issued - total [Number]: Number of spectacles issued to patients.
  • Spectacles issued to an adult - total [Number]: Number of spectacles issued to clients aged 19 years and older.
  • Spectacles issued to child - total [Number]: Number of spectacles issued to clients aged 7-18 years of age.
  • Spectacles required - total [Number]: Number of new spectacles (ordered) required for clients.
  • Spectacles required by an adult - total [Number]: Spectacles (ordered) required for clients aged 19 years and above.
  • Spectacles required by child - total [Number]: Spectacles (ordered) required for clients aged 7-18 years of age.
  • Wheelchairs issued - total [Number]: All wheelchairs issued to a client in need of a wheelchair.
  • Wheelchair issued adult 19 years and older [Number]: All wheelchairs issued to adults 19 years and older
  • Wheelchair issued child 0-18 years [Number]: All wheelchairs issued to children 0-18 years.
  • Wheelchair required - total [Number]: All wheelchair requests received at the facility.
  • Wheelchair required adult 19 years and older [Number]: All wheelchair requests received at the facility for adults 19 years and older.
  • Wheelchair required child 0-18 years [Number]: All wheelchair requests received at the facility for children 0-18 years.
  • Cataract surgery rate [per 1 million]: Clients who had cataract surgery per 1 million uninsured population.
  • Hearing aid issued adult 19 years and older rate [Percentage]: Hearing aids issued as a proportion of the applications for hearing aids received for adults 19 years and older.
  • Hearing aid issued child 0-18 years rate [Percentage]: Hearing aids issued as a proportion of the applications for hearing aids received for children 0-18 years.
  • Hearing aids issued rate [Percentage]: Hearing aids issued as a proportion of the applications for hearing aids received.
  • Prevalence of disability [Percentage]: Percentage of people reporting moderate to severe disability in a survey where disability is defined as a limitation in one or more activities of daily living (seeing, hearing, communication, moving, getting around, daily life activities, learning, intellectual and emotional).
  • Spectacles issued rate [Percentage]: Spectacles issued as a % of the applications received.
  • Spectacles issued to an adult rate [Percentage]: Spectacles issued to adults aged 19 years and above as a proportion of the applications received in adults aged 19 years and above (required).
  • Spectacles issued to child rate [Percentage]: Spectacles issued to children age 7-18 years as a proportion of the applications received in children 7-18 years of age (required).
  • Wheelchair issued adult 19 years and older rate [Percentage]: Wheelchairs issued as a proportion of the applications for wheelchairs received for adults 19 years and older.
  • Wheelchair issued child 0-18 years rate [Percentage]: Wheelchairs issued as a proportion of the applications for wheelchairs received for children 0-18 years.
  • Wheelchairs issued rate [Percentage]: Wheelchairs issued as a proportion of the applications for wheelchairs received.

The COVID-19 pandemic has highlighted the need for strategies to better reach the 15% of the population living with disabilities worldwide.36

4. Nutrition

The COVID-19 pandemic had various impacts on nutrition globally, ranging from disruptions in food-supply chains and decreased food security and affordability, to increased risk of obesity, and changes in eating habits and breastfeeding of babies.40

COVID-19 had a significant impact on the ability of mothers to breastfeed their babies due to fears of transmission.41 This led to a reduction in breastfeeding rates, as shown in Table 7, and an increased risk of malnutrition in infants. This reduction in breastfeeding appears to be persisting in South Africa across most provinces, except for Gauteng and the Western Cape where the rates of exclusive breastfeeding in infants remained fairly stable.

Table 7.Nutrition indicators by province, 2019-2022
Indicator Period        Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Infant exclusively breastfed at
DTaP-IPV-Hib-HBV 3rd dose rate
2019/20 both sexes DHIS 48,8 48,2 53,6 45,7 56,5 40,3 51,9 55,9 59,7 39,7 a
2020/21 both sexes DHIS 45,9 45,2 46,4 45,2 56,7 38,1 43,0 52,7 41,6 37,6 a
2021/22 both sexes DHIS 44,4 43,2 43,8 46,7 56,3 32,7 38,8 49,0 33,2 40,3 a
Overweight 2020 both sexes Under
5 years WHO
12,9 b
Stunting 2020 both sexes WHO 23,2 b
Vitamin A dose 12-59 months 2019/20 both sexes DHIS 5 302 353 772 904 226 520 1 067 632 1 455 506 496 909 466 125 80 536 265 752 470 469 a
2020/21 both sexes DHIS 3 898 515 540 386 198 276 850 985 898 699 409 577 345 116 69 451 209 734 376 291 a
2021/22 both sexes DHIS 4 428 184 577 730 203 706 982 671 1 030 246 439 413 400 232 73 845 271 654 448 687 a
Vitamin A dose 12-⁠59 months coverage 2019/20 both sexes DHIS 56,6 58,1 52,1 52,7 68,2 46,5 65,6 48,4 41,6 53,9 a
2020/21 both sexes DHIS 49,5 49,1 48,1 47,4 60,6 43,6 51,1 47,6 37,9 44,0 a
2021/22 both sexes DHIS 60,3 63,7 55,7 57,1 78,2 49,5 57,9 42,5 50,9 51,4 a

Reference notes
a webDHIS.10
b World Health Statistics 2022.32
Definitions

  • Vitamin A dose 12-59 months [Number]: Vitamin A dose given to a child, preferably every six months from 12 to 59 months.
  • Infant exclusively breastfed at DTaP-IPV-Hib-HBV 3rd dose rate [Percentage]: Infants exclusively breastfed at 14 weeks as a proportion of the DTaP-IPV-Hib-HBV 3rd dose vaccination. Take note that DTaP-IPV-Hib-HBV 3rd dose (Hexavalent) was implemented in 2015 to include the HepB dose.
  • Obesity [Percentage]: Percentage of people with a body mass index (BMI) (body mass in kg divided by the square of the height in m) equal to or more than 30kg/m2.
  • Overweight [Percentage]: Children: Proportion of children with weight for height over 2 standard deviations from the norm (reference population median). Adults: Percentage of people with body mass index (BMI) of 25-29.9 kg/m2. BMI is weight in kg divided by the square of height in m.
  • Stunting [Percentage]: Proportion of children with height for age under 2 standard deviations from the norm (reference population median).
  • Vitamin A dose 12-59 months coverage [Percentage]: Proportion of children 12-59 months who received vitamin A 200 000 units, preferably every six months. The denominator is therefore the target population 1-4 years multiplied by 2.

Vitamin A is vital to child health and immune function and programmes to control vitamin A deficiency contribute to a child’s chances of survival, reduce severity of childhood illnesses, and lead to overall reduction in child morbidity and mortality.42 As such, it was alarming to note the huge reduction in vitamin A doses administered in the country between 2019/20 and 2020/21, from 5.3 million to 3.9 million (Table 7). Administration of vitamin A has recovered somewhat, with the vitamin A dose coverage having increased from a low of 49.5% in 2020/21 to 60.3% 2021/22.

5. Health status indicators

5.1. Mortality

The 2022 edition of the World Health Organization’s World Health Statistics included an estimate of global mortality attributable to COVID-19, as of 20 April of that year.32 The WHO noted that although available data pointed to more than 4.7 million of the total of 6.2 million reported deaths having occurred in the Americas and European regions, mortality data in many countries were incomplete. One significant statistic, which was widely reported, was the estimate of excess mortality, which is defined as “the difference in the total number of deaths in a crisis compared to those expected under normal conditions”. Between January 2020 and December 2021, the full death toll associated directly and indirectly with the COVID-19 pandemic was approximately 14.9 million, exceeding the 5.4 million COVID-19 deaths by 9.5 million. Of these, 4.5 million excess deaths were estimated to have occurred in 2020, the balance of 10.4 million in 2021. The WHO pointed out that 10 countries, in which 35% of the global population resided, accounted for almost 70% of excess deaths worldwide. More than half of the excess deaths (53%) were estimated to have occurred in lower-middle-income countries, and more than a quarter (28%) in upper-middle-income countries. An attempt to estimate excess deaths, taking into account countries with incomplete data, came to a figure of 14.83 million excess deaths globally in the same 24-month period.43

In South Africa, the excess death reports44 generated by the South African Medical Research Council (SAMRC) were watched closely. Figure 4 and Table 8 show that a total of 339 146 excess deaths were estimated between May 2020 and December 2022. The close correlation between excess deaths and the first four ‘waves’ of COVID-19 is immediately evident, as is the more diffuse picture associated with the Omicron variant in 2022. The weekly excess-deaths reports were discontinued after December 2022. The SAMRC now reports on weekly number of deaths in South Africa on a monthly basis, the most recent being for February 2023. The revised reporting is only at national level, disaggregated by age groups and natural and unnatural causes.

Figure 4
Figure 4.Weekly deaths (all causes) in South Africa, 29 December 2019 - 10 December 2022

Source: SA MRC.44

Table 8.Number of excess natural deaths by province relative to revised predicted numbers, 2022
Region Period Excess deaths vs base Excess deaths per 100 000 population Age standardised excess deaths per 100 000
South Africa 3 May 20 - 10 Dec 22 33 9146 570 570
Eastern Cape 31 May 20 -⁠ 10 Dec 22 59 139 899 724
Free State 21 Jun 20 - 10 Dec 22 19 502 670 670
Gauteng 7 Jun 20 - 10 Dec 22 66 564 427 469
KwaZulu-⁠Natal 7 Jun 20 - 10 Dec 22 70 009 612 704
Limpopo 21 Jun 20 - 10 Dec 22 37 990 643 563
Mpumalanga 21 Jun 20 - 10 Dec 22 26 013 541 583
Northern Cape 28 Jun 20 - 10 Dec 22 10 338 883 826
North West 28 Jun 20 - 10 Dec 22 18 330 455 467
Western Cape 3 May 20 - 10 Dec 22 31 260 443 390

Source: SA MRC.44

Table 9 shows the life expectancy at birth for both sexes had dropped from 65.4 years in 2020 to 62 years in South Africa at the height of the COVID-19 pandemic in 2021. However, there was a slight recovery in 2022 and it increased to 62.8 for both sexes according to the Statistics South Africa mid-year population estimates.

Table 9.Mortality indicators by province, 2018 - 2022
Indicator Period Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Adult mortality (45q15 - probability
of dying between 15-60 years of age)
2018 both sexes RMS 31,0 a
female RMS 25,0 a
male RMS 37,0 a
2019 both sexes RMS 29,0 b
female RMS 24,0 b
male RMS 35,0 b
2020 both sexes RMS 31,0 b
female RMS 26,0 b
male RMS 36,0 b
Healthy life expectancy (HALE) 2019 both sexes WHO 56,2 c
56,2 d
female WHO 57,7 c
57,7 d
male WHO 54,6 c
54,6 d
Life expectancy at birth 2020 both sexes mid-year 65,4 e
both sexes RMS 64,7 b
female mid-year 68,5 f
female mid-year without HIV/AIDS 71,3 f
female RMS 67,2 b
female UNICEF 68,0 g
male mid-year 62,5 f
male mid-year without HIV/AIDS 64,6 f
male RMS 62,2 b
2021 HDR 62,3 h
both sexes mid-year 62,0 i
female mid-year 64,6 i
male mid-year 59,3 i
2022 both sexes mid-⁠year 62,8 e
female mid-year 65,6 e
male mid-year 60,0 e

Reference notes
a RMS 2018.45
b RMS 2019 & 2021.46
c World Health Statistics 2021.31
d World Health Statistics 2022.32
e Stats SA MYE 2022.11
f Stats SA MYE 2020.13
g SWChildren 2021.47
h HDR 2022.26
i Stats SA MYE 2021.12
Definitions

  • Adult mortality (45q15 - probability of dying between 15-60 years of age) [Percentage]: The probability of dying between 15 and 60 years of age (percentage of 15-year-olds who die before their 60th birthday).
  • Healthy life expectancy (HALE) [Years]: Healthy life expectancy or health-adjusted life expectancy is based on life expectancy at birth but includes an adjustment for time spent in poor health. It is most easily understood as the equivalent number of years in full health that a newborn can expect to live based on current rates of ill-health and mortality.
  • Life expectancy at birth [Years]: The average number of additional years a person could expect to live if current mortality trends were to continue for the rest of that person’s life.

5.2. Infectious diseases

Despite the impact of COVID-19, the number of malaria cases and deaths remained stable across the world without any major setbacks in malaria testing, prevention, and treatment services as countries intensified their efforts in their fight against malaria.48 Globally, the 2022 World Malaria report reported an estimated 619 000 deaths in 2021 compared to 625 000 in 2020 when the pandemic first hit, and 568 000 deaths pre-pandemic in 2019. Although the number of malaria cases continued to rise between 2020 and 2021, they rose at a slower rate than between 2019 and 2020. When looking at cases and deaths in the WHO African Region (Figure 5), which accounted for 95% of cases and 96% of deaths globally, there is an evident spike in both incidence and mortality rates in 2020, with reductions in both measures in 2021.

Figure 5
Figure 5.Malaria case incidence and mortality rates in the WHO African region, 2000-2021

Source: WHO estimates.48

South Africa was one of the countries that continued to make progress towards the elimination of malaria by 2025, with a 33.7% reduction in cases in 2021 compared to 2020. However, these figures could have been confounded by the reduction in testing due to limited movement during the lockdown periods when mobile clinics were unable to carry out testing and case investigations at community level. Furthermore, the country also recorded the highest increase in unclassified cases (one-third of total cases) over the past three years.48 A total of 4 109 malaria cases and 34 malaria deaths (Table 10) were reported by the National Department of Health (NDoH) from January 2022 to October 2022. In South Africa, malaria is classified as a category one Notifiable Medical Condition (MNC) that must be reported within 24 hours of diagnosis via written or electronic communication.49

At the beginning of 2022, the WHO and United Nations International Children’s Emergency Fund (UNICEF) reported an alarming increase in measles cases worldwide, with a 79% increase in the first two months of 2022 compared to the same period in the previous year. Health officials linked this surge in measles with the drop in vaccinations after the pandemic, as 23 million children missed out on all basic vaccinations in 2020. This represents the highest number of missed doses since 2009. COVID-19 disrupted childhood vaccinations as parents were apprehensive about taking their children to health facilities for fear of exposing them to COVID-19, and healthcare workers were reassigned to manage COVID-19 and moved away from doing routine vaccinations.50

South Africa also experienced a measles outbreak in October 2022. A total of 665 laboratory-confirmed measles cases were reported between 11 October 2022 and 24 February 2023 (Table 10) by the National Institute for Communicable Diseases (NICD). Although cases were reported across the country, outbreaks were declared in all provinces except the Eastern Cape. An outbreak is only declared once there are three or more classified laboratory measles cases reported within 30 days of onset of the disease. The most affected age groups were 5-9-year-olds (41% of cases), 1-4-year-olds (25% of cases) and 10-14-year-olds (20% of cases). In response to the outbreak, the NDoH initiated a national measles vaccination campaign for children aged between 6 months and 14 years, with the aim of limiting the outbreak. Health officials have been conducting vaccinations at schools, day-care centres and city clinics as part of the campaign to curb further spread of the outbreak.51

Table 10.Infectious disease indicators by province, 2018 - 2023
Indicator Period Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Reported cases of malaria 2020 both sexes all ages WHO 4 463 a
2021 both sexes all ages DOH surveillance 4 300 b
both sexes all ages WHO 2 958 a
2022 both sexes all ages DOH surveillance 4 109 b
Reported cases of measles 2018 WHO 52,0 c
2022/23 NICD lab diagnosed 665 4 24 90 15 232 100 5 185 10 d
Reported deaths from malaria 2020 both sexes all ages WHO 38 a
2021 both sexes all ages DOH surveillance 49 b
both sexes all ages WHO 56 a
2022 both sexes all ages DOH surveillance 34 b

Reference notes
a World Malaria 2022.48
b NICD Communique Dec 2022.49
c WHO Measles.28
d NICD Outbreak report 2023.52

5.3. Tuberculosis

Until the COVID-19 pandemic occurred, tuberculosis (TB) was one of the leading causes of death among the infectious diseases.53 According to the 2022 Global Tuberculosis Report, COVID-19 had a large impact on TB services globally.54 Worldwide, progress towards reducing TB disease burden slowed drastically, halted, and in some cases reversed, due to the pandemic.55 In South Africa, TB resources were redirected to address the demands posed by the pandemic.56 This redirection of resources affected the screening, diagnosis and treatment of TB, and slowed the progress made in the TB programme. South Africa is still among the five countries in the world with the highest TB incidence (Figure 6), although the situation has improved from 988 cases per 100 000 population per year in 2015 to 513/100 000 in 2021. South Africa is thus well on its way to reaching one of the 2025 End TB Milestones, namely a 50% reduction in TB incidence.57 However, the country needs to effectively implement the TB Recovery Plan, jointly developed by the National Department of Health and the TB Think Tank.55 Key to this effort is the concept of Targeted Universal Testing for TB (TUTT). Four key aims of the Plan are to reduce the number of undiagnosed people with TB, strengthen linkages to care, improve retention in care, and improve access to TB preventive treatment.

Figure 6
Figure 6.WHO global TB incidence by region (per 100 000 population per year), 2021

Source: WHO Global Health Observatory28

According to WHO estimations,57 304 000 people in South Africa developed TB in 2021, of whom only 181 699 were diagnosed and started on treatment. TB-related deaths were estimated at 55 000 in 2021, with 33 000 of those having a TB/HIV co-infection due to the high double burden of HIV and TB in South Africa, and people living with HIV being at higher risk of contracting TB. Based on local routine monitoring (Table 11), the number of newly diagnosed drug-sensitive TB patients decreased from a peak of 222 569 pre-COVID (April 2019 - March 2020) to 158 764 (April 2020 - March 2021), which represented a (-29%) decline in new TB diagnosis, reversing the progress that had been made in the TB programme. The public health facilities heeded the call to action by integrating COVID-19 services and TB services, among other evidence-based interventions, which resulted in the number of new diagnoses growing in the following financial year, to 195 640 (April 2021 - March 2022). This represents an 84% recovery towards the 2019 financial year TB diagnosis and treatment numbers.

Table 11
Table 11.TB diagnosis, year-on-year breakdown (provincial and national), 2019 - 2022

Source: webDHIS.10

Table 11 provides a breakdown of declines per province, showing a decline in TB diagnosis and treatment in all provinces during the 2020/21 financial year and some recovery in TB diagnosis and treatment the following financial year. However, none of the provinces have managed to reach TB diagnosis and treatment numbers to the level prior to COVID-19 (April 2019 - March 2020).

Figure 7 (national) and Figure 8 (provincial) show the impact of COVID-19 and the subsequent lockdown conditions on TB screening. Slow recovery from the initial lockdown restrictions (depicted in red) can be observed, with TB screening numbers not making a full recovery to pre-COVID TB screening figures.

Figure 7
Figure 7.Number of clients 5 years and older screened for TB symptoms in a facility (national), January 2020 - March 2022

Source: webDHIS10

Figure 8
Figure 8.Number of clients 5 years and older screened for TB in a facility by province, January 2020 - March 2022

Source: webDHIS10

The NDoH developed a National TB Recovery Plan58 with the aim of closing the gaps created by COVID-19, and leveraging good practices born from the response to COVID-19. Phase 1 (preparatory period) of the plan took place between January 2022 and June 2022, and Phase 2 (implementation period) began in July 2022 and ended in March 2023. The Plan outlined the following:

  • Finding undiagnosed people with TB through evidence-based interventions that scaled up community TB screening.55

  • The Targeted Universal TB Testing (TUTT) approach was strengthened. This offered, among other services, TB testing to people at high risk of contracting TB regardless of symptoms, as the National TB Prevalence Survey59 suggested that a large number of patients who develop TB present as asymptomatic.

  • Use of other technologies was scaled up, with a shorter turnaround time (TAT) for results compared to GeneXpert Ultra testing kits, which have a 48-hour TAT. These TB investigation tools will not replace GeneXpert Ultra testing, but will rather work alongside it. The TB diagnostic tools include, among others, the urine Lipoarabinomannan (LAM) screening (±25-minute TAT), digital X-rays (±20-minute TAT) and mobile self-screening applications. The latter proved to be effective in increasing COVID-19 screening coverage at a time of scarce human resources.

  • There was also an explicit effort to increase the focus on men, in response to the National TB Prevalence Survey59 which showed a higher prevalence of TB in males than females.

  • The recovery plan included strengthening of health systems that (i) support the TB programme, (ii) link people to TB care, and (iii) keep people in TB care through adherence counselling, hospital referrals to primary health care facilities, scale-up of shortened (6-month) multi-drug-resistant (MDR)-TB treatment regimens, 4-month paediatric treatment regimens for children, and strengthened tracer teams.

Figure 9 and Figure 10 show the impact of COVID-19 on TB diagnosis and treatment, with monthly data (24 months) displayed in relation to South African national lockdown levels from January 2020 to March 2022.

Figure 9
Figure 9.TB clients 5 years and older who started treatment in facility (national), January 2020 - March 2022

Source: webDHIS10

Figure 10
Figure 10.Drug-sensitive TB treatment started by persons 5 years and older, by province, January 2020 - March 2022

Source: webDHIS10

Drug-resistant (DR) TB was also negatively affected. There was a –32% decline in the number of people provided with treatment for rifampicin-resistant TB (RR-TB), while the number of people receiving MDR-TB treatment declined from 8 815 pre-COVID-19 to 6 016 in 2020/21, with a partial recovery to 7 005 (+16%) during 2021/22 (Table 12).

Table 12.TB indicators by province, 2019 - 2022
Indicator Period        Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
All DS TB patients in cohort 2019 both sexes DHIS 220 171 42 453 10 994 31 394 51 296 10 601 12 146 7 215 13 153 40 919 a
2020 both sexes DHIS 165 624 32 873 7 803 22 310 37 584 8 204 8 979 5 616 9 748 32 507 a
2021 both sexes DHIS 121 883 25 561 5 569 15 658 27 188 5 190 6 007 4 119 6 945 25 646 a
Case detection rate (all forms) 2020 both sexes Global TB 58 b
2021 both sexes Global TB 57 b
DS TB patients who completed treatment or were cured 2018 both sexes all ages DHIS 174 583 30 909 8 633 27 955 41 577 9 221 10 479 3 720 7 553 34 536 a
2019 both sexes DHIS 176 032 33 474 8 520 26 340 42 449 8 289 9 823 5 409 10 334 31 394 a
2020 both sexes DHIS 130 598 25 697 5 824 18 387 31 184 6 377 7 233 3 844 7 708 24 344 a
Incidence of TB (all types) (per 100 000) 2019 both sexes WHO 615 c
2020 both sexes WHO 554 d
both sexes Global TB 562 b
2021 both sexes Global TB 513 b
Screen for TB symptoms 5 years and older 2019/20 both sexes DHIS 88 341 637 11 911 051 4 997 501 17 309 676 23 697 914 10 873 851 6 544 049 1 569 752 4 881 165 6 556 678 a
2020/21 both sexes DHIS 70 565 171 9 493 199 3 546 481 14 079 732 19 132 526 9 023 591 5 270 205 1 236 609 3 752 773 5 030 055 a
2021/22 both sexes DHIS 80 942 655 10 532 623 3 607 012 17 268 185 21 143 838 9 727 357 6 018 633 1 593 266 4 385 597 6 666 144 a
Screen for TB symptoms under 5 years 2019/20 both sexes DHIS 17 647 545 2 154 997 926 337 3 204 481 4 514 276 2 584 786 1 547 206 291 499 938 084 1 485 879 a
2020/21 both sexes DHIS 13 189 701 1 715 142 650 304 2 468 495 3 384 940 1 876 971 1 137 773 219 538 657 298 1 079 240 a
2021/22 both sexes DHIS 15 632 660 1 977 308 716 311 3 010 670 3 776 483 2 231 014 1 386 491 286 590 834 127 1 413 666 a
TB child under 5 years start on treatment rate 2019/20 DHIS 11,3 9,6 4,5 15,0 11,1 7,6 3,5 11,6 10,1 40,7 a
2020/21 DHIS 93,2 99,5 103,7 80,0 92,4 62,9 122,3 70,1 108,7 99,2 a
2021/22 DHIS 94,8 79,6 65,6 98,7 101,8 105,7 87,6 114,4 108,9 96,5 a
TB client 5 years and older start on treatment rate 2019/20 DHIS 97,0 98,3 97,6 95,5 99,0 98,8 101,1 99,5 99,9 90,0 a
2020/21 DHIS 94,8 93,0 93,2 93,4 96,4 96,2 96,0 99,8 95,3 90,3 a
2021/22 DHIS 93,4 92,7 90,6 94,8 94,8 97,2 93,4 87,9 95,3 91,4 a
TB DS client lost to follow up rate 2019 both sexes DHIS 12,6 13,8 10,8 8,5 10,0 9,6 10,5 18,8 12,4 18,6 a
2020 both sexes DHIS 12,0 13,3 11,6 7,9 8,4 7,7 8,4 22,1 10,0 18,8 a
2021 both sexes DHIS 13,0 14,5 14,3 7,5 9,1 7,1 7,0 25,2 7,8 20,7 a
TB DS death rate 2019 both sexes DHIS 7,4 7,5 10,6 7,4 7,5 12,5 9,0 7,3 9,5 3,9 a
2020 both sexes DHIS 8,3 7,7 12,5 9,2 8,0 13,7 10,4 8,4 10,3 5,2 a
2021 both sexes DHIS 8,3 8,0 13,4 9,5 8,1 13,3 9,6 8,6 9,1 5,2 a
TB DS treatment success rate 2019 both sexes DHIS 79,3 77,9 77,3 83,6 81,9 77,2 80,0 72,6 77,6 76,5 a
2020 both sexes DHIS 78,9 78,2 74,6 82,4 83,0 77,7 80,6 68,4 79,1 74,9 a
2021 both sexes DHIS 77,9 76,6 71,3 82,5 82,1 78,9 82,8 64,9 82,1 73,0 a
TB MDR client death rate 2019 both sexes DHIS 16,6 18,6 26,7 18,4 13,4 24,3 20,9 13,7 16,8 13,3 a
2020 both sexes DHIS 17,5 19,2 26,6 19,1 16,0 17,8 20,0 20,1 16,6 13,6 a
TB MDR client loss to follow up rate 2019 both sexes DHIS 15,2 16,5 10,7 15,3 13,2 8,1 6,6 21,5 10,7 22,8 a
2020 both sexes DHIS 16,5 16,8 11,2 16,9 13,9 11,7 9,4 16,0 9,4 25,5 a
TB MDR treatment success rate 2019 both sexes EDRWeb 60,7 60,4 59,1 58,7 66,0 55,8 66,3 60,3 65,4 51,6 a
2020 both sexes DHIS 60,8 60,1 56,1 60,5 66,1 64,3 68,5 61,2 65,8 51,3 a
TB symptom 5 years and older screened in facility rate 2019/20 both sexes DHIS 88,6 85,7 110,1 98,1 99,7 95,3 87,1 68,9 76,6 53,4 a
2020/21 both sexes DHIS 87,6 85,7 85,9 98,9 98,3 88,9 86,1 65,2 70,9 61,9 a
2021/22 both sexes DHIS 95,8 90,6 89,3 111,4 104,9 95,2 95,7 80,1 80,0 72,5 a
TB symptom child under 5 years screened in facility rate 2019/20 both sexes DHIS 87,6 85,4 109,5 87,3 98,2 88,0 90,5 64,8 70,3 71,5 a
2020/21 both sexes DHIS 88,9 91,8 95,8 90,7 101,4 83,9 94,7 69,1 65,4 73,9 a
2021/22 both sexes DHIS 92,6 95,5 97,7 95,8 100,9 88,2 96,1 83,3 74,3 80,6 a
TB XDR client death rate 2019 both sexes DHIS 19,1 19,7 35,7 27,6 10,4 50,0 31,3 14,3 0,0 17,7 a
2020 both sexes DHIS 16,5 19,2 0,0 17,4 13,7 0,0 16,7 21,4 5,9 a
TB XDR client loss to follow up rate 2019 both sexes DHIS 12,1 10,9 7,1 6,9 11,7 0,0 12,5 28,6 0,0 16,1 a
2020 both sexes DHIS 17,8 19,2 25,0 8,7 15,7 0,0 33,3 28,6 11,8 a
TB XDR started on treatment 2019 both sexes DHIS 461 239 14 29 77 2 16 21 1 62 a
2020 both sexes DHIS 315 182 4 23 51 1 6 14 0 34 a
TB XDR successfully complete treatment 2019 both sexes DHIS 284 152 7 18 58 1 7 10 1 30 a
2020 both sexes DHIS 169 94 0 14 28 0 3 6 0 24 a
TB XDR treatment success rate 2019 both sexes EDRWeb 49,9 52,1 46,2 51,7 55,8 50,0 25,0 47,6 0,0 41,9 a
2020 both sexes DHIS 53,7 51,6 0,0 60,9 54,9 0,0 50,0 42,9 70,6 a

Reference notes
a webDHIS.10
b Global TB Report 2022.54
c World Health Statistics 2021.31
d World Health Statistics 2022.32
Definitions

  • All DS TB patients in cohort [Number].
  • DS TB patients who completed treatment or were cured [Number].
  • Screen for TB symptoms 5 years and older [Number]: Clients 5 years and older who were screened in health facilities for TB symptoms using the standard TB screening tool as per National TB Guideline.
  • Screen for TB symptoms under 5 years [Number]: Children under 5 years who were screened in health facilities for TB symptoms using the standard TB screening tool as per National TB Guideline.
  • TB XDR started on treatment [Number]: Number of XDR-TB patients who started treatment.
  • TB XDR successfully complete treatment [Number]: Extensive Drug Resistant TB (XDR-TB) clients successfully treated at the end of the treatment.
  • TB child under 5 years start on treatment rate [Percentage]: TB client under 5 years started on treatment as a proportion of ALL symptomatic children under 5 years.
  • TB client 5 years and older start on treatment rate [Percentage]: TB client 5 years and older start on treatment as a proportion of TB symptomatic client 5 years and older test positive.
  • TB DS client lost to follow-up rate [Percentage]: The percentage of TB clients (all types of TB) who defaulted treatment.
  • TB DS death rate [Percentage]: The percentage of TB clients (all types of TB registered in ETR.net) who died.
  • TB DS treatment success rate [Percentage]: The percentage of TB clients (all types registered in ETR.net) cured plus those who completed treatment.
  • TB MDR client death rate [Percentage]: The percentage of TB clients (MDR TB) who died.
  • TB MDR client loss to follow-up rate [Percentage]: The percentage of TB clients (MDR TB) who are lost to follow-up.
  • TB MDR treatment success rate [Percentage]: The percentage of TB clients (MDR TB) cured plus those who completed treatment.
  • TB symptom child under 5 years screened in facility rate [Percentage]: Children under 5 years screened for TB symptoms as a proportion of PHC headcount under 5 years.
  • TB XDR client death rate [Percentage]: The percentage of TB clients (XDR TB) who died.
  • TB XDR client loss to follow-up rate [Percentage]: The percentage of TB clients (XDR TB) who are lost to follow-up.
  • TB XDR treatment success rate [Percentage]: TB XDR clients successfully complete treatment as a proportion of TB XDR clients started on treatment.

Figure 11 shows that preventive therapy for children under 5 years (shown in light blue) declined in performance consistently over the 2019-2022 period. This is particularly concerning as TB is very difficult to diagnose in children under 5 years, as the children are unable to articulate their symptoms, and parents find it challenging, or are sometimes unaware of, the changes to take note of in their children that would indicate the presence of TB. As such, TB in children under 5 years of age must become an explicit area of focus for TB programmes in South Africa. Gastric washout is the most commonly used procedure to diagnose TB in children under 5 years of age; however, it is a very invasive procedure that makes parents reluctant to provide consent, among other factors. A few clinical research initiatives have attempted to solve this challenge. However, data indicate that these types of research initiatives need to be prioritised and invested in so that there can be accelerated learning and calibration, and treatment can be rolled out as soon as possible to this high-TB-risk population subset.

Figure 11
Figure 11.National TB performance against targets, 2018-2022

Source: webDHIS10

5.4. HIV and AIDS

Figure 12 shows that by March 2022, the number of HIV tests performed nationally appeared to have recovered to pre-pandemic levels. However, the impact of the COVID-19 pandemic on HIV response should not be under-estimated as the figures for March 2022 were lower than what was forecasted. Figure 13 shows the same trend for most provinces with the exception of the Northern and Western Cape and Limpopo where HIV testing numbers had reached the estimated forecasted levels for March 2022. Figure 14 to Figure 16 graphically illustrate the impact on treatment initiations and retention in care. In a high HIV and TB burden setting, COVID-19 has been associated with high mortality among people living with HIV.60 A divergence is noted in the antiretroviral effective coverage figures between the modelled Thembisa 4.5 estimates and the routine coverage from webDHIS (Table 13), which could be the result of the momentum lost during the COVID-19 period.

Figure 12
Figure 12.HIV tests done (national), January 2020 - March 2022

Source: webDHIS10

Figure 13
Figure 13.HIV tests per province, January 2020 - March 2022

Source: webDHIS10

Figure 14
Figure 14.ART client start ART during month (national), January 2020 - March 2022

Source: webDHIS10

Figure 15
Figure 15.ART client start ART during month by province, January 2020 - March 2022

Source: webDHIS10

Figure 16
Figure 16.ART client remain on ART (national), January 2020 - March 2022

Source: webDHIS10

Figure 17
Figure 17.ART client remain on ART by province, January 2020 - March 2022

Source: webDHIS10

Table 13.HIV and AIDS indicators by province, 2018- 2022
Indicator Period Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Adult living with HIV 2020 Q1 both sexes 15+ years NDoH-Thembisa 7 174 336 808 940 403 021 1 866 419 1 950 240 461 625 668 118 79 737 501 315 434 921 a
2021 Q1 both sexes 15+ years NDoH-Thembisa 7 157 513 820 796 396 195 1 752 754 1 854 967 567 873 683 117 101 051 498 164 482 596 a
2022 Q1 both sexes 15+ years NDoH-Thembisa 7 518 945 833 869 389 880 1 836 580 1 911 616 664 333 717 174 103 808 514 813 546 872 a
Child living with HIV 2020 Q1 both sexes 0-⁠14 years NDoH-Thembisa 326 567 42 576 19 529 58 700 100 371 27 699 35 720 4 862 23 536 13 574 a
2021 Q1 both sexes 0-14 years NDoH-Thembisa 268 935 36 519 17 079 48 685 73 354 27 081 26 420 5 854 18 756 15 187 a
2022 Q1 both sexes 0-14 years NDoH-Thembisa 270 599 32 056 14 767 49 277 75 076 30 986 31 336 4 428 18 645 14 028 a
Total living with HIV 2020 Q1 both sexes all ages NDoH-Thembisa 7 500 903 851 516 422 550 1 925 119 2 050 611 489 324 703 838 84 599 524 851 448 495 a
2021 Q1 both sexes all ages NDoH-Thembisa 7 426 448 857 315 413 274 1 801 439 1 928 321 594 954 709 537 106 905 516 920 497 783 a
2022 Q1 both sexes all ages NDoH-Thembisa 7 789 544 865 925 404 647 1 885 857 1 986 692 695 319 748 510 108 236 533 458 560 900 a
People living with HIV (PLHIV) 2020 both sexes 0-14 years Global Report 310 000 b
both sexes all ages Global Report 7 800 000 b
both sexes all ages mid-year 7 800 000 c
both sexes all ages Thembisa 4.4 7 892 070 863 517 404 619 1 878 400 1 985 710 692 685 746 915 107 814 532 097 556 517 d
both sexes ILO in labour force 4 887 632 e
female 15 + years Global Report 4 800 000 b
female ILO in labour force 2 607 391 e
male 15+ years Global Report 2 700 000 b
male ILO in labour force 2 280 241 e
2021 both sexes all ages Thembisa 4.4 8 008 080 874 329 405 266 1 910 980 1 992 300 704 108 754 254 109 608 538 115 574 861 d
2022 both sexes all ages Thembisa 4.5 7 975 940 900 332 415 029 1 849 650 2 034 810 706 564 752 696 112 561 544 074 586 425 f
Percentage of people living with HIV (PLHIV)
who know their status (1st 90)
2019 both sexes all ages Global Report 92,0 g
female 15+ years Global Report 94,0 g
male 15+ years Global Report 91,0 g
2020 both sexes 0-14 years Global Report 75,0 b
both sexes all ages Global Report 92,0 b
female 15+ years Global Report 94,0 b
male 15 years Global Report 91,0 b
HIV prevalence (age 15-49) 2020 both sexes 15-49 years mid-year 18,7 c
female 15-49 years mid-year 23,0 c
2021 both sexes mid-year 19,5 h
2022 both sexes mid-year 19,6 i
HIV prevalence (total population) 2020 both sexes all ages mid-year 13,0 c
both sexes all ages Thembisa 4.3 13,2 13,7 15,0 12,4 17,9 10,8 15,9 9,9 13,8 7,6 j
both sexes all ages Thembisa 4.4 13,4 13,3 14,0 12,0 17,6 11,9 15,6 9,6 13,3 8,1 d
both sexes ILO in labour force 23,9 e
female ILO in labour force 30,2 e
male ILO in labour force 19,3 e
2021 both sexes all ages Thembisa 4.4 13,4 13,4 14,0 12,0 17,5 12,0 15,5 9,7 13,2 8,2 d
both sexes mid-year 13,7 h
2022 both sexes all ages Thembisa 4.5 13,5 14,1 14,7 11,8 18,1 12,0 15,8 10,1 13,6 8,4 f
both sexes mid-year 13,9 i
Adult ART Total 2020 Q1 both sexes 15+ years DHIS 4 866 047 511 867 282 727 1 109 761 1 436 613 366 875 498 211 61 567 305 498 292 928 a
2021 Q1 both sexes 15+ years DHIS 4 981 934 526 288 288 816 1 115 574 1 467 110 381 963 520 366 58 798 331 156 291 863 a
2022 Q1 both sexes 15+ years DHIS 5 148 692 551 615 298 996 1 160 906 1 506 479 399 243 534 821 57 815 338 111 300 706 a
Child ART Total 2020 Q1 both sexes 0-14 years DHIS 148 396 18 849 10 151 23 425 44 482 13 755 16 394 4 015 9 295 8 030 a
2021 Q1 both sexes 0-14 years DHIS 135 459 17 284 8 204 21 088 41 226 12 372 15 602 3 673 8 516 7 494 a
2022 Q1 both sexes 0-14 years DHIS 123 135 16 224 7 401 19 191 35 473 11 638 14 726 3 511 7 669 7 302 a
Number of patients receiving ART 2020 both sexes all ages Thembisa 4.3 5 286 810 559 312 297 082 1 181 960 1 465 490 404 000 493 116 72 224 315 454 334 966 j
both sexes all ages Thembisa 4.4 4 976 670 565 489 299 766 1 175 690 1 522 030 405 754 539 588 69 361 334 696 315 474 d
2020 Q1 both sexes all ages DHIS 5 014 443 530 716 292 878 1 133 186 1 481 095 380 630 514 605 65 582 314 793 300 958 a
2021 both sexes all ages Thembisa 4.4 5 240 800 590 495 306 668 1 219 410 1 557 130 426 306 562 597 72 965 349 713 334 444 d
2021 Q1 both sexes all ages DHIS 5 111 503 542 488 295 260 1 136 123 1 508 568 394 362 533 347 62 383 339 532 299 440 a
2022 both sexes all ages Thembisa 4.5 5 631 460 592 901 315 868 1 249 670 1 583 250 437 523 562 923 70 949 359 946 336 590 f
2022 Q1 both sexes all ages DHIS 5 271 827 567 839 306 397 1 180 097 1 541 952 410 881 549 547 61 326 345 780 308 008 a
Total Clients remaining on ART at the end of the month Mar 2020 both sexes all ages DHIS 5 020 308 531 135 294 215 1 134 719 1 481 679 381 733 514 347 66 439 315 571 300 470 a
Mar 2021 both sexes all ages DHIS 5 117 541 543 572 296 971 1 136 662 1 508 336 394 335 536 165 62 471 339 672 299 357 a
Mar 2022 both sexes 15+ years DHIS 5 271 827 567 839 306 397 1 180 097 1 541 952 410 881 549 547 61 326 345 780 308 008 a
Antiretroviral coverage (2nd 90) 2020 both sexes 0-14 years Global Report 47,0 b
both sexes all ages GBD 72,8 k
both sexes all ages Global Report 72,0 b
both sexes all ages Thembisa 4.3 68,4 61,7 67,4 61,8 71,4 64,5 65,3 64,0 57,7 64,4 j
both sexes all ages Thembisa 4.4 71,9 71,4 80,2 68,1 81,3 64,8 78,3 70,5 68,7 62,3 d
female 15+ years Global Report 78,0 b
male 15 years Global Report 63,0 b
2021 both sexes all ages Thembisa 4.4 73,7 73,3 81,5 69,6 82,5 66,6 80,4 72,8 70,7 64,0 d
2022 both sexes all ages Thembisa 4.5 75,0 71,3 80,9 72,2 81,1 67,9 79,2 69,1 70,9 62,4 f
Clients remaining on ART rate Mar 2020 both sexes all ages DHIS 66,9 62,4 69,4 58,9 72,2 77,8 73,1 77,5 59,9 67,1 a
Mar 2021 both sexes all ages DHIS 68,9 63,4 71,9 63,1 78,2 66,3 75,6 58,4 65,7 60,1 a
Mar 2022 both sexes all ages DHIS 67,7 65,6 75,7 62,6 77,6 59,1 73,4 56,7 64,8 54,9 a
Antiretroviral effective coverage 2020 both sexes all ages Thembisa 4.3 63,3 56,0 63,5 55,3 67,6 57,6 60,2 58,4 52,9 60,6 j
both sexes all ages Thembisa 4.4 66,4 65,5 74,1 62,6 76,7 58,6 72,2 64,4 62,9 56,7 d
2020 Q1 both sexes 0-14 years DHIS-Tier 18,7 19,1 17,4 18,8 21,2 19,1 20,2 13,9 17,5 a
both sexes 15+ years DHIS-Tier 41,8 37,8 39,9 41,6 49,0 53,6 52,5 17,8 37,7 a
both sexes all ages DHIS-Tier 40,8 36,8 38,8 40,9 47,6 51,6 50,8 17,6 36,8 a
2021 both sexes all ages Thembisa 4.4 68,3 67,6 75,7 63,8 78,2 60,6 74,6 66,6 65,0 58,2 d
2021 Q1 both sexes all ages DHIS-Tier 45,5 39,9 43,9 45,0 52,6 44,2 50,3 22,5 43,5 32,6 a
2022 both sexes all ages Thembisa 4.5 70,6 65,9 76,1 67,6 77,8 61,9 74,8 63,1 66,2 57,4 f
2022 Q1 both sexes all ages DHIS-Tier 45,1 40,0 49,9 45,3 56,0 36,5 50,6 21,5 43,8 20,0 a
Adult with viral load suppressed rate 12 months 2020 Q1 both sexes 15+ years DHIS 88,1 86,8 89,7 87,6 90,6 86,5 86,2 83,6 85,5 a
2021 Q1 both sexes 15+ years DHIS 88,6 88,6 89,3 88,7 89,1 88,3 88,3 83,3 86,5 90,3 a
2022 Q1 both sexes 15+ years DHIS 88,9 86,7 92,8 91,3 90,5 79,9 87,7 85,0 84,3 91,6 a
Child with viral load suppressed rate 12 months 2020 Q1 both sexes 0-14 years DHIS 63,9 62,9 64,3 64,3 68,8 51,5 60,9 75,2 65,3 a
2021 Q1 both sexes 0-14 years DHIS 65,3 62,3 72,5 65,2 53,1 68,4 64,0 69,8 68,0 64,5 a
2022 Q1 both sexes 0-14 years DHIS 60,7 63,2 61,4 63,2 55,8 62,3 53,1 59,4 69,3 a
ART client viral load suppressed rate (VLS) 2020 Q1 both sexes all ages DHIS-Tier 87,5 85,9 89,0 87,1 89,9 85,3 85,5 83,2 84,9 a
2021 Q1 both sexes all ages DHIS 88,0 87,8 89,1 88,3 88,5 87,3 87,7 81,5 86,1 88,6 a
2022 Q1 both sexes all ages DHIS 88,0 86,0 92,0 91,0 90,0 79,0 87,0 84,0 84,0 91,0 a
HIV viral load suppression (3rd 90) 2020 both sexes 0-14 years Global Report 33,0 b
both sexes all ages Global Report 66,0 b
both sexes all ages Thembisa 4.3 92,5 90,6 94,1 89,4 94,6 89,3 92,3 91,2 91,7 94,2 j
both sexes all ages Thembisa 4.4 59,6 57,1 68,8 55,4 71,0 51,0 64,3 57,7 56,2 52,7 d
female 15+ years Global Report 72,0 b
male 15 years Global Report 58,0 b
2021 both sexes all ages Thembisa 4.4 62,8 60,8 71,5 58,2 73,7 54,4 68,2 61,2 59,7 55,1 d
2022 both sexes all ages Thembisa 4.5 64,0 57,4 70,6 60,7 72,2 53,9 67,6 55,8 60,0 53,6 f
Infant PCR test positive around 10 weeks rate 2018/19 both sexes DHIS 0,7 1,0 0,7 0,7 0,6 0,7 0,9 1,4 0,9 0,3 a
2019/20 both sexes DHIS 0,7 0,9 0,5 0,7 0,5 0,7 0,9 1,3 0,9 0,3 a
2020/21 both sexes DHIS 0,6 0,7 0,5 0,7 0,4 0,7 0,6 1,0 0,7 0,3 a
Adult living with HIV viral load done 12m 2020 Q1 both sexes 15+ years DHIS-Tier 3 403 846 352 021 179 121 886 716 1 055 123 286 134 406 715 16 964 221 052 a
2021 Q1 both sexes 15+ years DHIS 3 734 509 377 554 198 456 898 715 1 111 108 292 891 396 112 27 698 255 405 176 570 a
2022 Q1 both sexes 15+ years DHIS 3 899 389 391 707 214 659 924 923 1 210 061 312 055 425 359 27 427 273 492 119 706 a
Adult living with HIV viral load suppressed (VLS) 12m 2020 Q1 both sexes 15+ years DHIS 2 999 406 305 530 160 656 776 624 955 434 247 396 350 673 14 188 188 905 a
2021 Q1 both sexes 15+ years DHIS 3 317 696 334 432 178 051 799 532 992 743 258 942 350 454 23 238 220 859 159 445 a
2022 Q1 both sexes 15+ years DHIS 3 464 855 339 499 199 254 844 446 1 095 505 249 401 373 072 23 306 230 668 109 704 a
Adult remaining on ART at end of the month - total Mar 2020 both sexes 15+ years DHIS 4 872 515 512 268 284 952 1 111 128 1 437 205 367 756 497 964 62 524 306 262 292 456 a
Mar 2021 both sexes 15+ years DHIS 4 980 854 526 288 288 767 1 115 574 1 467 110 381 963 519 335 58 798 331 156 291 863 a
Mar 2022 both sexes 15+ years DHIS 5 148 692 551 615 298 996 1 160 906 1 506 479 399 243 534 821 57 815 338 111 300 706 a
Antenatal client initiated on ART rate 2019/20 female DHIS 96,2 95,3 98,4 97,2 98,4 95,2 98,8 93,4 98,1 80,2 a
2020/21 female DHIS 94,9 91,8 98,1 98,6 98,9 96,8 96,6 88,6 93,2 67,9 a
2021/22 female DHIS 95,0 90,4 97,7 99,3 98,9 98,0 97,6 90,4 90,3 68,5 a
Antenatal client start on ART 2019/20 female DHIS 94 440 10 536 4 126 25 746 21 207 9 871 10 526 1 563 6 020 4 845 a
2020/21 female DHIS 82 021 8 893 3 451 22 662 18 524 8 853 9 450 1 389 4 993 3 806 a
2021/22 female DHIS 68 045 7 827 3 173 17 969 16 121 7 358 7 041 1 210 4 090 3 256 a
Child living with HIV viral load done 12m 2020 Q1 both sexes 0-14 years DHIS-Tier 95 581 12 927 5 290 17 137 30 907 10 262 11 865 898 6 295 a
2021 Q1 both sexes 0-14 years DHIS 93 422 11 737 4 852 16 731 31 182 7 988 9 986 1 186 5 526 4 234 a
2022 Q1 both sexes 0-14 years DHIS 84 890 10 748 4 293 14 590 27 318 8 134 10 702 180 5 445 3 480 a
Child living with HIV viral load suppressed (VLS) 12m 2020 Q1 both sexes 0-14 years DHIS 61 099 8 127 3 400 11 021 21 255 5 284 7 227 675 4 110 a
2021 Q1 both sexes 0-14 years DHIS 61 022 7 309 3 520 10 916 21 329 4 243 6 387 828 3 760 2 730 a
2022 Q1 both sexes 0-14 years DHIS 51 530 6 790 2 634 9 224 17 022 4 535 5 679 3 235 2 411 a
Child under 15 years remaining on ART at end of the month - total 2021 Q1 both sexes 0-14 years DHIS 136 687 17 284 8 204 21 088 41 226 12 372 16 830 3 673 8 516 7 494 a
Mar 2020 both sexes 0-14 years DHIS 147 793 18 867 9 263 23 591 44 474 13 977 16 383 3 915 9 309 8 014 a
Mar 2022 both sexes 0-14 years DHIS 123 135 16 224 7 401 19 191 35 473 11 638 14 726 3 511 7 669 7 302 a
HIV testing coverage 2020 both sexes 15+ years Thembisa 4.3 77,7 74,0 73,1 75,9 79,0 75,1 74,6 75,1 76,7 76,2 j
both sexes 15+ years Thembisa 4.4 77,7 75,7 75,4 79,0 80,9 76,4 77,0 76,5 79,2 78,1 d
2021 both sexes 15+ years Thembisa 4.4 78,2 76,5 75,8 79,2 81,7 77,1 77,6 77,0 79,7 78,6 d
2022 both sexes 15+ years Thembisa 4.5 82,9 79,9 75,5 83,8 86,2 78,4 77,8 77,7 82,5 82,4 f
Infant 1st PCR test positive at birth rate 2019/20 both sexes DHIS 0,6 0,5 0,4 0,5 0,3 0,6 1,0 0,4 1,3 0,8 a
2020/21 both sexes DHIS 0,5 0,5 0,3 0,6 0,4 0,5 0,8 0,6 0,6 0,8 a
2021/22 both sexes DHIS 0,4 0,4 0,1 0,5 0,3 0,5 0,3 0,8 0,5 0,8 a
Medical male circumcision 15 years and older rate 2019/20 DHIS 46,4 59,5 32,2 38,3 47,6 24,4 52,5 51,6 61,1 71,2 a
2020/21 DHIS 59,1 88,6 73,5 38,9 79,2 85,9 67,4 59,8 94,5 91,2 a
2021/22 DHIS 55,8 79,3 50,3 38,5 60,1 78,7 68,6 40,5 84,3 92,5 a
Percentage of deaths due to AIDS 2020 both sexes all ages mid-year 15,4 c
2021 both sexes all ages mid-year 12,2 h
Total living with HIV viral load done 12m 2020 Q1 both sexes all ages DHIS-Tier 3 499 427 364 948 184 411 903 853 1 086 030 296 396 418 580 17 862 227 347 a
2021 Q1 both sexes all ages DHIS-Tier 3 448 279 363 218 178 204 842 785 1 045 472 282 163 360 744 21 816 243 727 110 150 a
2022 Q1 both sexes all ages DHIS 3 984 279 402 455 218 952 939 513 1 237 379 320 189 436 061 27 607 278 937 123 186 a
Total living with HIV viral load suppressed 12m 2020 Q1 both sexes all ages DHIS 3 060 505 313 657 164 056 787 645 976 689 252 680 357 900 14 863 193 015 a
2021 Q1 both sexes all ages DHIS 3 035 283 318 804 158 778 744 538 925 390 246 225 316 453 17 781 209 772 97 542 a
2022 Q1 both sexes all ages DHIS 3 516 385 346 289 201 888 853 670 1 112 527 253 936 378 751 23 306 233 903 112 115 a

Reference notes
a webDHIS.10
b UNAIDS 2021.61
c Stats SA MYE 2020.13
d Thembisa v4.4.62
e HIV and work 201863
f Thembisa v4.5.64
g UNAIDS Data 2020.65
h Stats SA MYE 2021.12
i Stats SA MYE 2022.11
j .Thembisa v4.3.66
k GBD 2017 HIV.67
Definitions

  • Adult ART Total [Number].:
  • Adult living with HIV [Number]: Estimated number of adults (15+ years) living with HIV.
  • Adult living with HIV viral load done 12m [Number].
  • Adult living with HIV viral load suppressed (VLS) 12m [Number]: ART client with suppressed viral load (VLS) of under 400 copies per millilitre (cps/mL).
  • Adult remaining on ART at end of the month - total [Number].
  • ART Adult client viral load done (VLD) [Number].
  • ART Child client viral load done (VLD) [Number].
  • Child ART Total [Number].
  • Child living with HIV [Number]: Estimated number of children (0-14 years) living with HIV.
  • Child living with HIV viral load done 12m [Number].
  • Child living with HIV viral load suppressed (VLS) 12m [Number]: ART client with suppressed viral load (VLS) of under 400 copies per millilitre (cps/mL).
  • Number of patients receiving ART [Number]: Number of patients receiving ART.
  • People living with HIV (PLHIV) [Number]: The number of people who are HIV-positive.
  • Total clients remaining on ART at the end of the month [Number].
  • Total living with HIV [Number]: The estimated number of people who are HIV-positive.
  • Total living with HIV viral load done 12m [Number].
  • Total living with HIV viral load suppressed 12m [Number]: ART client with suppressed viral load (VLS) of under 400 copies per millilitre (cps/mL) at 12 months.
  • Adult with viral load suppressed rate 12 months [Percentage]: Proportion of ART clients with viral load suppressed at different time intervals. This indicates the population level immunological impact of clients on ART.
  • Antenatal client initiated on ART rate [Percentage]: Antenatal clients on ART as a proportion of the total number of antenatal clients who are HIV positive and not previously on ART.
  • Antiretroviral coverage (2nd 90) [Percentage]: The number of patients receiving ART, divided by the number needing treatment. The denominator has changed over time, due to changes in treatment guidelines affecting the criteria for treatment eligibility. The latest definition is that all HIV-infected patients should be on ART. This indicator is also one of the 90-90-90 global targets for AIDS (UNAIDS).
  • Antiretroviral effective coverage [Percentage]: Proportion of HIV-positive people on ART and virally suppressed. Any implausible values (>100) capped at 100, zero or missing values set to 1.
  • ART client viral load suppressed rate (VLS) [Percentage]: ART viral load suppressed - total as a proportion of ART viral load done
  • Child with viral load suppressed rate 12 months [Percentage]: Proportion of ART clients with viral load suppressed at different time intervals. This indicates the population level immunological impact of clients on ART.
  • Clients remaining on ART rate [Percentage]: Percentage of estimated people living with HIV who remain on ART. (Routine data equivalent for antiretroviral coverage).
  • HIV prevalence (age 15-49) [Percentage]: Percentage of population (age 15-49) estimated to be HIV-positive.
  • HIV prevalence (total population) [Percentage]: Percentage of population estimated to be HIV-positive.
  • HIV testing coverage [Percentage]: Percentage of target population who have been tested for HIV.
  • HIV viral load suppression (3rd 90) [Percentage]: Percentage of people on ART who are virologically suppressed (VL level ≤1 000 copies/mL). This indicator is also one of the 90-90-90 global targets for AIDS (UNAIDS).
  • Infant 1st PCR test positive at birth rate [Percentage]: Infants tested PCR positive for the first time at birth as proportion of infants PCR tested at birth.
  • Medical male circumcision 15 years and older rate [Percentage]: Medical male circumcisions performed 15 years and older as a proportion of total medical male circumcisions performed.
  • Percentage of deaths due to AIDS [Percentage]: Percentage of total deaths attributed to AIDS related causes.
  • Percentage of people living with HIV (PLHIV) who know their status (1st 90) [Percentage]: Percentage of people living with HIV who know their HIV status. This indicator is also one of the 90-90-90 global targets for AIDS (UNAIDS).

The UNAIDS summary page on South Africa68 shows data for 2021, in the middle of the pandemic. Although new infections continued to decline, the rate at which HIV-related deaths were declining, slowed. These statistics provide the backdrop to the recently launched National Strategic Plan (NSP) for HIV, TB and STIs 2023-2028.69 Emphasis in the NSP 2023-2028 has been described as follows: “to provide innovative, people- and communities-centred interventions and multi-sectoral approaches to reduce the barriers and enhance access to equitable HIV, TB and STI prevention and treatment services”. This intent is closely aligned with the Global AIDS Strategy 2021-2026.70 However, policy objectives on paper do not translate easily into actionable interventions in the clinical setting. This was demonstrated in a cluster randomised controlled study conducted in 40 rural clinics in South Africa.71 Attempts to integrate HIV and TB services, with a quality-improvement component, failed to show an impact on mortality in HIV-TB co-infected patients. Even in sub-populations that have been the target of concerted effort over many years, such as pregnant women, reaching the third of the 95-95-95 targets has proven challenging.72 Table 19 shows the medical male circumcision (MMC) rates fluctuated between 2019/20 and 2021/22 which could have been the effect of some variations among the provinces where MMC rates went up quite drastically particularly between 2019/20 and 2020/21.

5.5. COVID-19

As the COVID-19 disease burden in South Africa and globally has reduced, so the frequency with which COVID-19 statistics are reported has dropped considerably. Although the dedicated COVID-19 website (https://sacoronavirus.co.za/) remains operative, it no longer gives daily statistics. Instead, the weekly COVID-19 reports now have to be accessed via the National Institute for Communicable Diseases (NICD) website (https://www.nicd.ac.za/diseases-a-z-index/disease-index-covid-19/surveillance-reports/). Most tellingly, the Daily Hospital Surveillance (DATCOV) reporting system is no longer functioning. This system had been highlighted as a prime example of collaboration between the public and private sectors, with 100% of all hospitals in each sector contributing data. The weekly DATCOV site only provides data until December 2022, and includes this note: “Please note: the DATCOV system ended at the end of December 2022 and COVID-19 hospitalisation data will be collected via the Notifiable Medical Conditions surveillance system from January 2023. These weekly COVID-19 hospitalisation reports have been discontinued from 31 December 2022.” Without weekly reporting, it is uncertain whether the COVID-19 hospitalisations are being consistently reported via the notifiable medical conditions (NMC) system. How many ambulatory cases are reported as NMCs is also uncertain. The rolling total on the South African coronavirus website showed 4 055 656 COVID-19 cases on 3 April 2023 and 102 595 deaths.

The weekly testing summary also ceased, from the end of March 2023 (epidemiological week 12 of 2023). The final report showed that 12 180 Polymerase Chain Reaction (PCR) tests were conducted in the week to 25 March 2022, bringing the cumulative national total to 21 577 962 since 1 March 2020.73 Interpreting the PCR percentage testing positive was no longer simple, as testing strategies varied between provinces. For example, settings in which all antigen-positive tests were confirmed by PCR would bias the statistic.

Although optional booster vaccinations are now accessible for all adults, uptake of COVID-19 vaccinations has slowed dramatically. Figures 18-20 show the vaccination statistics as at 20 February 2023. In March 2023, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) revised its guidance.74 Additional booster doses were not recommended for healthy adults (those under the age of 50-60 years without comorbidities) and children and adolescents with comorbidities. Booster vaccination was still recommended for those at higher risk, namely older adults, younger adults with significant comorbidities (e.g. diabetes and heart disease), people with immune-compromised conditions (e.g. people living with HIV and transplant recipients; including children aged 6 months and older), pregnant persons, and frontline health workers. Children 5-11 years old at risk of severe disease became eligible for a primary course of vaccination from the end of February 2023.75

Figure 18
Figure 18.Total number of individuals vaccinated, by province, 20 February 2023
Figure 19
Figure 19.Individuals vaccinated as % of the population, 20 February 2023
Figure 20
Figure 20.Individuals vaccinated as % of the population by age group, 20 February 2023

5.6. Maternal and reproductive health

It has been found that during all pandemics, public focus shifts to preserving life, with less attention given to women, children, and reproductive health.76 The number of antenatal visits declined in all provinces during level 5 of the South African lockdown in 2020-2022 as illustrated in Figure 21 and Figure 22. All the provinces showed a significant increase in number of antenatal visits as lockdown levels lowered. All provinces, except for the Free State, experienced a drop in number of visits. This drop continued into the 2021/22 year, except in the Eastern Cape, where visits improved compared with the previous year, from 68.2% in 2020/21 to 81.2% in 2021/22. All provinces noted a reduction in the number of contraceptives methods prescribed (measured by the couple year protection rate) during lockdown levels 4 and 5; however, contraceptive prescription went back to usual as lockdown levels decreased (Figure 23 and Figure 24). All provinces showed an improvement in the couple year protection rate, except Gauteng, which declined from 44.9% in 2020/21 to 37.8% in 2021/22, and the Northern Cape which declined from 50.9% in 2020/21 to 46.8% in 2021/22 as shown in Table 14.

Figure 21
Figure 21.Antenatal 1st visit coverage (national), January 2020 - March 2022

Source: webDHIS10

Figure 22
Figure 22.Antenatal 1st visit coverage per province, January 2020 – March 2022

Source: webDHIS10

Figure 23
Figure 23.Couple year protection rate (national), January 2020 - March 2022

Source: webDHIS10

Figure 24
Figure 24.Couple year protection rate per province, January 2020 – March 2022

Source: webDHIS10

Table 14.Maternal health indicators by province, 2018- 2022
Indicator Period        Sex|Age|Series|Cat SA EC FS GP KZ LP MP NC NW WC Ref
Antenatal 1st visit before 20 weeks rate 2019/20 female DHIS 69,7 62,5 66,6 66,5 74,5 69,0 77,4 65,0 70,9 71,9 a
2020/21 female DHIS 67,9 62,5 61,3 63,3 74,6 66,8 74,9 58,6 68,0 70,6 a
2021/22 female DHIS 68,9 63,0 60,5 66,8 74,2 66,7 74,3 56,3 70,1 72,6 a
Antenatal 1st visit coverage 2019/20 female DHIS 83,1 68,7 79,3 90,2 75,0 90,7 92,7 105,6 77,7 91,1 a
2020/21 female DHIS 83,9 68,2 78,5 88,3 76,3 93,9 107,4 109,9 76,4 86,7 a
2021/22 female DHIS 81,5 81,2 78,9 82,5 77,3 88,0 87,6 88,6 72,1 82,6 a
Cervical cancer screening coverage 2019/20 female DHIS 46,8 50,0 46,0 42,2 55,9 33,3 57,9 32,0 55,9 41,8 a
2020/21 female DHIS 27,8 31,5 29,5 17,8 40,5 21,5 41,3 13,9 25,7 28,0 a
2021/22 female DHIS 36,9 32,9 35,2 31,4 56,8 25,1 42,7 15,3 22,8 40,0 a
Couple year protection rate 2019/20 DHIS 54,5 55,2 78,9 43,7 56,5 55,3 48,2 56,6 62,4 64,5 a
2020/21 DHIS 49,8 41,0 74,9 44,9 51,5 46,9 39,8 50,9 48,0 50,5 a
2021/22 DHIS 50,3 49,0 84,7 37,8 60,3 51,9 39,2 46,8 52,3 56,9 a
Delivery 10-14 years in facility 2019/20 female DHIS 3 870 671 192 631 704 447 618 134 149 324 a
2021/22 female 10-14 years DHIS 3 963 627 147 549 993 518 419 101 216 393 a
Delivery 10-19 years in facility 2018/19 DHIS 124 628 17 167 5 779 14 920 35 471 16 587 11 819 4 041 7 857 10 987 a
2021/22 female 10-19 years DHIS 139 361 18 960 6 647 20 877 35 820 18 070 14 425 3 976 9 424 11 162 a
Delivery 15-19 years in facility 2019/20 female DHIS 127 028 17 211 6 054 15 251 35 467 18 363 11 786 3 870 7 922 11 104 a
2021/22 female 15-19 years DHIS 135 398 18 333 6 500 20 328 34 827 17 552 14 006 3 875 9 208 10 769 a
Delivery by Caesarean section rate 2019 female med schemes 77,5 b
2019/20 female DHIS 29,0 30,9 31,8 31,2 33,7 21,4 22,4 21,5 25,0 29,9 a
2020/21 female DHIS 27,8 31,7 30,4 30,3 35,3 23,1 21,0 23,9 24,1 30,0 a
2021/22 female DHIS 29,6 32,3 32,3 30,6 36,4 23,2 20,3 22,2 23,4 30,9 a
Delivery by Caesarean section rate (district hospitals) 2019/20 female DHIS District Hospital 24,7 25,4 14,9 27,5 28,2 22,5 21,2 15,5 29,8 27,2 a
2020/21 female DHIS District Hospital 24,4 25,5 13,9 30,7 29,1 24,8 20,2 19,9 28,9 27,0 a
2021/22 female DHIS District Hospital 25,9 25,9 14,0 33,2 29,3 24,4 20,4 15,7 28,6 28,5 a
Delivery in 10 to 19 years in facility rate 2019/20 female DHIS 13,2 16,7 12,7 7,5 16,3 14,1 14,9 18,4 13,1 11,1 a
2020/21 female DHIS 14,3 17,1 13,1 8,9 16,5 13,8 15,5 19,3 14,0 10,8 a
2021/22 female DHIS 13,7 17,4 13,3 9,1 16,6 13,5 15,8 17,6 15,0 11,2 a
Delivery in facility rate 2019/20 female DHIS 79,3 61,4 87,5 75,2 78,4 94,9 88,1 98,4 72,9 89,5 a
2020/21 female DHIS 82,1 62,4 85,9 82,7 76,0 100,6 97,8 92,1 74,6 90,6 a
2021/22 female DHIS 83,3 77,8 92,7 81,5 79,0 100,2 88,2 82,0 72,6 84,6 a
Early neonatal death in facility rate 2019/20 both sexes DHIS 9,6 10,0 11,9 9,3 8,7 12,5 9,6 13,1 9,5 6,5 a
2020/21 both sexes DHIS 9,7 10,4 11,9 9,6 9,4 10,6 10,3 11,5 10,8 6,5 a
2021/22 both sexes 0 DHIS 10,0 10,3 12,6 10,5 9,8 10,7 10,5 10,3 11,1 6,1 a
Female condoms distributed 2018/19 DHIS 17 658 915 2 579 661 1 218 303 3 760 346 3 397 759 1 737 808 1 951 650 333 100 782 888 1 897 400 a
2019/20 DHIS 16 562 153 1 775 000 1 397 300 4 867 267 2 804 576 1 982 950 1 231 300 248 950 773 910 1 480 900 a
2021/22 DHIS 17 487 705 2 089 400 1 421 800 5 228 585 3 813 200 738 500 1 997 762 113 700 931 858 1 152 900 a
Live birth under 2500g in facility rate 2019/20 both sexes DHIS 12,9 14,1 14,2 13,9 11,7 10,6 11,6 18,9 13,6 13,9 a
2020/21 both sexes DHIS 13,2 13,6 14,4 13,0 11,8 10,7 11,5 16,7 13,3 13,6 a
2021/22 both sexes 0 DHIS 13,2 14,3 14,8 14,0 12,3 10,6 12,0 18,2 14,0 14,4 a
Male condom distribution coverage 2019/20 DHIS 32,1 34,7 52,3 25,1 30,1 35,5 32,8 28,9 38,7 33,2 a
2020/21 DHIS 26,5 22,3 50,9 26,3 26,6 27,5 23,9 23,8 27,4 21,4 a
2021/22 DHIS 26,1 22,4 56,1 21,1 29,0 28,3 19,1 20,9 28,1 27,3 a
Male condoms distributed 2019/20 DHIS 646 587 444 78 817 157 53 246 000 135 857 486 108 503 920 67 818 200 51 749 400 12 959 400 55 579 921 82 055 960 a
2020/21 DHIS 542 144 989 51 122 509 52 248 000 146 303 254 96 529 200 53 325 900 38 316 000 10 825 929 39 841 971 53 632 226 a
2021/22 DHIS 545 372 354 45 839 588 55 352 800 129 075 303 106 967 000 52 862 900 31 364 066 9 518 000 42 361 097 72 031 600 a
Maternal mortality in facility ratio 2019/20 female DHIS 88,0 108,2 116,2 102,9 76,9 97,8 67,1 109,9 88,0 43,6 a
2020/21 female DHIS 120,9 146,2 178,8 118,7 123,9 120,1 108,3 80,6 124,6 83,9 a
2021/22 female DHIS 119,1 114,6 156,5 129,3 100,6 134,6 130,0 157,5 129,9 75,1 a
Mother postnatal visit within 6 days rate 2019/20 female DHIS 80,1 69,0 80,5 85,5 76,1 104,2 70,9 68,6 93,2 60,1 a
2020/21 female DHIS 76,6 71,2 79,9 75,0 76,2 94,7 73,9 66,8 94,9 53,7 a
2021/22 female DHIS 78,6 78,6 76,6 74,7 79,3 95,2 74,2 61,1 102,6 57,1 a
Neonatal death in facility rate 2019/20 both sexes DHIS 11,9 12,3 15,6 12,4 10,9 14,3 11,2 15,5 11,5 8,2 a
2020/21 both sexes DHIS 12,6 13,1 16,0 13,2 12,1 12,7 12,7 13,8 13,9 8,3 a
2021/22 both sexes DHIS 13,1 13,2 15,9 14,3 13,0 13,2 12,9 12,9 14,6 7,7 a
Neonatal mortality rate (NMR)
(deaths <28 days old per 1 000 live births)
2018 both sexes WHO 11,0 c
both sexes RMS 11,0 d
2019 both sexes WHO 11,0 e
both sexes GBD 20,7 f
2020 both sexes WHO 11,0 g
RMS 12,0 h
Perinatal death in facility rate 2019/20 both sexes DHIS 29,1 29,0 35,4 27,9 29,7 31,7 28,2 36,8 31,0 22,9 a
2020/21 both sexes DHIS 29,8 31,3 38,7 29,1 32,7 30,9 13,3 33,9 33,9 24,6 a
2021/22 both sexes DHIS 30,8 30,3 38,6 29,5 32,3 29,5 31,1 43,6 33,2 24,1 a
Perinatal mortality rate (stillbirths plus deaths
<8 days old per 1 000 total births)
2018/19 both sexes DHIS 30,1 28,3 39,9 28,6 30,8 31,7 30,2 34,3 30,6 25,6 a
2019/20 both sexes DHIS 25,0 18,8 32,7 24,3 24,5 32,0 26,5 37,9 23,9 21,7 a
2021/22 both sexes DHIS 27,2 25,4 38,1 25,4 27,3 31,1 29,0 38,0 24,8 21,6 a
Stillbirth in facility rate 2019/20 both sexes DHIS 19,7 19,2 23,8 18,8 21,2 19,5 18,8 24,0 21,7 16,5 a
2020/21 both sexes DHIS 19,9 21,1 27,1 19,7 23,6 20,5 3,0 22,6 23,4 18,3 a
2021/22 both sexes DHIS 21,0 20,1 26,3 19,2 22,8 19,0 20,8 33,6 22,4 18,1 a
Teenage pregnancy 2021 female 14-19 years GHS 2,7 i
ToPs (Terminations of Pregnancy) 2019/20 DHIS 124 446 12 597 7 776 23 048 27 441 14 960 8 127 1 497 9 806 19 194 a
2020/21 DHIS 103 350 9 696 6 888 22 832 21 754 13 660 2 494 1 454 8 367 16 205 a
2021/22