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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.

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

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.

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.

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 diabetes^23,24 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

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.

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

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.

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.

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.

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.

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.

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

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.

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 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.

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.

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).

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.

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.

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

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.

The crisis-management approach to the pandemic, which included lockdowns, school closures, and travel restrictions, placed women and adolescent girls at risk of having their rights violated, resulting in early pregnancy, gender-based violence, and lack of access to reproductive health services. The webDHIS figures in Table 14 show that deliveries by adolescents between the ages of 10 and 19 years increased across all provinces in 2021/22 compared to 2018/19. These findings underscore the importance of policies and programmes that provide life-skills training, financial literacy, support, and safe spaces for adolescent girls and women.⁸⁰ There was also a significant increase in the maternal mortality ratio (MMR) in 2020/21 as noted in Table 14 where the MMR ranged from 178.8 in the Free State to 80.6 in the Northern Cape. This again points to the damaging effects of COVID-19 on maternal health.

There was a huge drop in cervical screening coverage between 2019/20 and 2021/21 due to COVID-19 and its effect on the national screening coverage programme. Cervical screening coverage rates were already low nationally at 46.8% and had still not recovered in 2021/22 (36.9%) yet cervical cancer is the second leading cause of cancer death among women following breast cancer.⁸¹

5.7. Child health

The global under-5-year mortality rate dropped to 37 deaths per 1 000 live births in 2020, but children in the African Region continued to have the highest mortality rates worldwide.³²

Under-5 mortality (U5MR) continues to be one of the most challenging public health issues in LMICs, mainly due to poor dwelling units, poor access to breastfeeding, and the circumstances of birth, more specifically multiple births as these children are more likely to die than singleton children⁸² The leading causes of under-5 mortality are neonatal causes, diarrhoea, and pneumonia or lower respiratory tract infections, despite there being a high immunisation coverage rate and a decreasing occurrence of malnutrition.⁸³ COVID-19 has resulted in a setback in achieving reduced deaths from infections and maternal and child health conditions that would have been possible by the year 2035. COVID-19 disrupted childhood vaccination programmes due to lockdowns, and redirected spending towards emergencies, including the procurement of COVID-19 vaccines.⁸⁴

The monthly webDHIS figures (Figure 25 and Figure 26) indicate that immunisation coverage has stayed stable in the country, with a slight increase across all provinces except for North West in 2021/22. This could be due to the levels of lockdown having been gradually lifted at the time. The incidence of pneumonia cases decreased during higher levels of lockdown, driven in part by reduced care-seeking behaviours and patients only presenting for severe cases (Figure 27 and Figure 28). Figure 29 and Figure 30 show that cases of diarrhoea and dehydration also declined during higher levels of lockdown and increased slightly as restrictions were eased.

5.8. Non-communicable diseases

In 2022 the NDoH published the National Strategic Plan for the Prevention and Control of Non-Communicable Diseases, 2022-2027⁸⁷ to fast-track their response towards the prevention and control of non-communicable diseases (NCDs), risk factors and mental conditions. This was also in recognition of the gaps that COVID-19 exposed in the delivery of NCD services as mortality and hospitalisation rates were much higher for those living with NCDs (both known and unknown) and among obese people in the country.⁸⁸ The NSP proposed a cascade-based strategy similar to the 90-90-90 approach for HIV and AIDS, and TB. The proposed 90-60-50 cascade states that:

• 90% of all people over 18 will know whether or not they have raised blood pressure and/or raised blood glucose.

• 60% of people with raised blood pressure or blood glucose will receive intervention.

• 50% of people receiving interventions are controlled.⁸⁷

NCD policies require increasingly efficient implementation as the attributable burden for diabetes mellitus is growing. For example, improved surveillance of risk factors, including physical activity, is crucial to improving NCD detection and response.⁸⁹ A high mortality burden attributable to high systolic blood pressure underscores the need for improved care for hypertension and cardiovascular diseases, particularly stroke, to prevent morbidity and mortality.⁹⁰

As mentioned before, South Africa’s population is ageing and those living with HIV are living longer due to the successful uptake of antiretroviral therapy (ART), which means that the NCD burden on the country will also increase as old age is a risk factor for developing an NCD. In 2022, Percept Actuaries & Consultants quantified the burden of NCDs in South Africa using datasets that included the General Household Survey, the National Income Dynamics Study (NiDS), the South Africa Demographic and Health Survey (2016/17), cause-of-death records, Council for Medical Schemes data, underwriting from insurers, National Health Accounts, and webDHIS data. Some key findings from the briefs were:

• South African males were 1.38 times more likely than females to have diabetes. Among the medical scheme population, the odds of being male with hypertension were 1.17 times higher than the odds of being female with hypertension.

• Objective measures of diabetes showed high prevalence of undiagnosed or poorly managed diabetes. Only 30% of men and women with diabetes reported that they had previously been diagnosed with diabetes.

• Uncontrolled diabetes increased the risk of death among hospitalised COVID-19 patients; the risk of death was exacerbated in elderly males, and those who had co-morbidities such as hypertension, clotting disorders, cardiovascular disease and obesity.⁹¹

Data on NCDs continues to be difficult to find though, as NCDs are not notifiable medical conditions (NMC). However, there has been an improvement in this regard as cancer registries are being strengthened. Table 16 shows the cancer incidence rate in South Africa for 2020, as reported by the National Cancer Registry (NCR) by cancer type. The most prevalent cancers in the country are prostate, breast, cervical, lung and colorectal. Figure 31 illustrates the age-standardised incidence rates among males and females for cancers with the highest incidence in the country.

According to the International Disability Alliance’s report³⁷ on COVID-19 and diabetes, diabetes was a strong risk factor for adverse COVID-19 outcomes; individuals with diabetes were more likely to be hospitalised or die as a result of COVID-19 infections than those not living with the disease. The International Diabetes Federation (IDF) 2021 Atlas⁹² estimated that South Africa has the highest number of people living with diabetes in Africa, with an estimate of 4.2 million people in 2021. Twelve years ago, in 2011, this figure was estimated at just 1.9 million. According to routine data collected in the webDHIS between 2020/21 and 2021/22, there were noticeable drops in the number of new diabetes and hypertension treatment clients in the public sector. This was another indication of potential under-screening and under-diagnosing due to disruptions to health services caused by COVID-19 (Table 16).

COVID-19 highlighted increasing concern around mental health, both globally and locally. The second annual Mental State of the World Report⁹³ noted that mental wellbeing showed a greater decline in 2020 (8%) than in 2021 (3%). This correlates with the stringent COVID-19 measures taken by governments when the pandemic started, and directly correlates with the number of cases and deaths per million.⁹³ The report further noted that the pandemic had the greatest effect on the mental well-being of younger generations worldwide, with 44% of 18-24-year-olds considered in the ‘Distressed’ or ‘Struggling’ range compared with only 7% of those aged 65 years and older. The Mental Health Quotient (MHQ) assessment “captures a comprehensive spectrum of emotional, social and cognitive attributes encompassing both problems (or symptoms) across 10 different mental health disorders (as defined by the DSM-5), as well as positive mental attributes. An aggregate mental wellbeing score based on these aspects (the MHQ) positions individuals on a spectrum from Distressed to Thriving.” South Africa and the UK had the lowest MHQ (a score of 46) among the 34 countries included in the assessment; according to the scale, this score was in the ‘Enduring’ range (Figure 32). Furthermore, South Africa stood out among all the other countries as the percentage of ‘Distressed’ or ‘Struggling’ increased by 8% from 28.55% in 2020 to 36% in 2021. Such indicators demonstrate the increasing need for comprehensive mental health action plans, and mental health programmes and services in the country.

5.9. Injuries and risk behaviours

In 2022, the Global Burden of Disease (GBD) alcohol group estimated the population-level risks of alcohol consumption by amount, geography, age, sex, and year. They recommended the development of tailored guidelines and recommendations on alcohol consumption by age and across regions due to the fact that existing low consumption thresholds were actually too high for younger populations. Additionally, the publication noted that young adult males are the highest consumers of alcohol globally, and interventions targeting them should be prioritised to minimise loss of health due to alcohol consumption.⁹⁴

Research by the Alcohol Harms Reduction programme forecasts a marked reduction in alcohol-related health costs if legislative interventions increase the price of alcohol through minimum unit pricing, and if the availability of liquor is reduced by regulating outlet trading hours⁹⁵

In South Africa, alcohol remains an important contributor to the overall disease burden, ranking fifth in terms of deaths and disability-adjusted life years (DALYs).⁹⁶ In 2021, most alcohol and drug treatment and rehabilitation centres re-opened following closures during the height of the COVID-19 pandemic. The most recent report from the South African Community Epidemiology Network on Drug Use (SACENDU) covered both periods in 2021 (January-June, and July-December). It reported an increased number of admissions for alcohol and other drugs (AODs) in the second half of the year, from 10 938 (across 85 centres/programmes) to 15 704 (across 78 treatment centres/programmes) as shown in Table 17. There was a higher number of people seeking treatment for alcohol in the Western Cape and Gauteng, and a decline of 21% for such admissions in KwaZulu-Natal. Cannabis was the main drug of use among admissions aged 20 years and younger (Table 17).⁹⁷

6. Health service indicators

6.1. Health facilities

Figures 33 and 34 show the overall impact of the COVID-19 pandemic on health facility workload. Despite the direct workload associated with confirmed COVID-19 cases, the overall number of patient-day equivalents was below the predicted level until March 2022, as was in-patient bed utilisation (Figure 35 and Figure 36).

The national bed utilisation rate (BUR) during the COVID-19 period dropped from 72.4% in 2019/20 to 60.7% but the average length of stay (ALOS) remained at 4 days. The inpatient crude death rate increased from 4.6% to 5.7% indicating that although less patients were admitted during the time, more patients probably died as a result of COVID-19. By contrast, primary health care (PHC) utilisation recovered to predicted levels over the same period, as shown in Figure 37 and Figure 38.

Figure 39 to Figure 40, along with Table 18, show that the PHC utilisation rate for children under five is also on a steady recovery to pre-COVID levels in most provinces with the exception of the Northern Cape which had a PHC utilisation rate of 4.3 in 2019/20 and has only increased to 2.7 in 2021/22. Table 18 also illustrates how the total PHC headcount between 2019/20 and 2020/21 declined which resulted in less patients being seen by doctors and PHC professional nurses. This confirms the lack of essential services rendered to clients. The PHC headcount had still remained lower in the country in 2022 with only 101 393 994 people visiting PHCs compared to 2019 where it was estimated at close to 120 million people.

6.2. Health personnel

The health personnel data provided in Table 19 and Table 20 only reflect those working in the public sector. The COVID-19 pandemic underscored the interrelatedness of the public and private health sectors, and enabled cross-sector service provision in one limited sense. The national COVID-19 vaccination programme was able to draw on the capacity of both sectors to deliver vaccine doses, regardless of insurance status. Changes to the reimbursement processes in early 2023 have reduced access to services in the private sector, with vaccine administration costs no longer reimbursed for uninsured persons.¹⁰³

Lack of human resources for health remains a constant feature of many health systems, even in more well-resourced settings. A Global Burden of Disease (GBD) 2019 mapping exercise set targets of 20.7 physicians per 10 000 population, 70.6 nurses and midwives, 8.2 dentistry personnel, and 9.4 pharmaceutical personnel, in order to reach a universal health coverage index of 80 out of 100.¹⁰⁵ On this basis, the 2019 global health workforce was estimated to be missing 6.4 million physicians, 30.6 million nurses and midwives, 3.3 million dentistry personnel, and 2.9 million pharmaceutical personnel. Not surprisingly, the lowest health worker densities were recorded in sub-Saharan Africa, south Asia, North Africa and the Middle East. There was a noticeable increase in the medical doctors professional nurses, enrolled nurses, nursing assistants and pharmacists per 100 000 uninsured population between March 2020 and March 2021 as more professionals were appointed to work during the COVID-19 pandemic. The numbers, however, declined in March 2022 to be in line with March 2020 levels.

6.3. Health financing

As shown in Table 21, medical scheme coverage has continued to decline as a percentage of the total population. The Council for Medical Schemes’ 2021 Industry Report noted a further minor consolidation in the number of medical schemes.¹⁹ In 2021, there were 75 registered medical schemes, of which 57 were restricted and 18 open. This was almost half the number of schemes operating in the year 2000 (144 schemes, 97 restricted, 47 open). In 2021, the medical schemes disbursed a total of R205.3 billion in benefits, representing a 15.3% increase from 2020. The average amount paid per beneficiary per annum was R23 060.79. Although it is difficult to compare the expenditure patterns with those ordinarily reported for the public sector (as shown in Table 21), the following headline amounts are striking: medical schemes spent 35.7% of their overall disbursements (from risk and savings) on hospital services, 28.1% on specialists, and 16.1% on medicine dispensed outside of hospitals (by pharmacies and dispensing practitioners). Total hospital expenditure increased by 18.7% between 2020 and 2021 as illustrated in Table 22, with almost all benefits (92%) being paid to private hospitals. Year-on-year, medicines expenditure outside of hospitals increased by 9.2%. In the public sector, normalised expenditure on primary health care and district health services expenditure was distinctly higher in 2020/21 in real terms compared with the previous and following financial years; expenditure per headcount increased by almost 50% nationally in 2020/21. This was the result of the drop of the PHC headcount from almost 120 million in 2019/20 to 95 million in 2020/21 and also the drops in the BUR/OPD headcount and PDE in those periods (Figure 41 and Table 23).

7. Conclusion

While the world and South Africa are still in the early post-COVID era, there is already a global (and national) focus on learning lessons from the pandemic in order to build a more resilient health system that can be responsive to unexpected shocks. Strong health-information systems should be the foundation on which evidence-based decisions can be made in order to support strong governance and leadership, where human resources for health are also supported and healthcare funding is prioritised. However, there is also an understandable tendency to revert to the status quo ante to recover lost ground and reinstate systems that were compromised. This is particularly true in a setting of extreme fiscal constraint, where health systems in the public sector are being asked to accept real declines in funding and the private sector continues to face unaffordable increases in medical scheme subscription costs for a stagnant and aging risk pool. Where health-information systems that bridged the divide between the public and private sectors lose funding, the previous fragmentation is re-imposed. Lessons learned risk being lost, despite the lip-service paid to post-pandemic preparedness and response frameworks.