Introduction

During the COVID-19 pandemic, a staggering 765 million cases and 6.9 million deaths were reported worldwide. On 5 May 2023, the Director-General of the World Health Organization, Dr Tedros Ghebreyesus, officially declared that the COVID-19 no longer constituted a public health emergency of international concern. Despite this declaration, Ghebreyesus cautioned that the virus was “still killing” and mutating, and urged countries to examine their pandemic performance to avoid repeating mistakes.¹

This edition of the South African Health Review offers promising examples of COVID-19 response, mitigation, and recovery strategies. Emerging lessons from these efforts may be used to enhance our health system resilience and better prepare us for future pandemics.

Overview of chapters

In chapter one, George et al. investigate the willingness of healthcare workers (HCWs) to promote COVID-19 vaccines, as well as their perceived level of knowledge and communication skills when interacting with patients. The research findings indicate a positive correlation between the vaccination behaviour of healthcare personnel and their inclination to promote vaccination among their patients. A significant number of HCWs indicated that they faced challenges in obtaining access to reliable, credible, evidence-based, and trustworthy sources of information related to vaccines. The authors concluded that enhancing the operational efficiency of HCWs and their ability to communicate proficiently with patients necessitates the provision of readily accessible, clear, pertinent, and current evidence-based information.

Chapter two highlights the work of the Ministerial Advisory Committee (MAC) on COVID-19. The MAC was established in March 2020, with the aim of offering top-level strategic and technical input on various COVID-19 topics. Reflecting on the development of more than 150 advisories, Gray and colleagues foreground the importance of focusing on the best available evidence rather than waiting for the best possible evidence; they also emphasise the importance of emergency response transparency, and reinforce the importance of creating avenues for accommodating public participation, particularly in time-sensitive contexts. The authors’ recommendation is for South Africa to emulate other countries by formulating secondary legislation that would facilitate the prompt establishment of an advisory committee during emergency situations. Ideally, the panel of experts should be pre-identified and readily available for prompt deployment during emergency situations. However, it is important to maintain flexibility in order to recruit individuals with relevant expertise based on the specific nature of the crisis.

In chapter 3, Kannemeyer and colleagues investigate the role of health committees (also known as clinic committees) in the Western Cape during the COVID-19 pandemic and reflect on the importance of health committees in outbreak control. The authors describe the many activities carried out by committee members as a result of close contact with their communities, activities that National Department of Health (NDoH) employees were unable to carry out. The authors examine the relationship that evolved between health committees and the NDoH during the COVID-19 pandemic, reporting on how increasing agency on the part of health committees enabled them to grow in confidence and claim access to previously inaccessible spaces. However, the authors highlight persistent power disparities between clinic committees and government, which might stymie successful collaboration between the two groups, particularly in ‘invited spaces’ where authority lies with government.

In chapter 4, Peters and colleagues report on public-private project at Groote Schuur Hospital to resolve a backlog of roughly 10 000 surgical cases caused by surgical service de-escalation during the COVID-19 pandemic. The authors argue that the volume of services provided in the public sector can be increased by using external capital funding for human resources, equipment, and consumables, and that these services become truly effective when accompanied by adequate multidisciplinary planning, alignment, and support at operational, strategic, and executive levels of healthcare facilities.

In chapter 5, Madela-Mntla and Ngcobo describe some of the adaptive efforts made by the University of Pretoria’s Department of Family Medicine (UPDFM) to deliver on its mandate of teaching, learning, and research in the face of the COVID-19 pandemic disruptions during the March-September 2020 nationwide hard lockdown. The authors describe actions taken by the Department to address issues such as lack of effective COVID-19 screening instruments, inadequate communication and care coordination, limited access to medicine and care, and a lack of acceptable COVID-19 information in various languages. The authors believe that the UPDFM’s initiatives and lessons learned during the crisis proved invaluable for use beyond the acute phase of the pandemic, altering the health system for better pandemic preparedness.

In chapter six, Kruger et al. analyse the impact of the COVID-19 pandemic on the utilisation of routine maternal, neonatal, child, and women’s health (MNCWH) services in Tshwane District. The study reveals that the pandemic had a significant adverse impact on access to healthcare services for women and children. The authors recommend that future-proofing the health system for significant disruptive events like COVID-19 requires planning for service delivery and client access, especially at community level. They also suggest that while curative care may need to be prioritised in emergency situations, preventive interventions should not be neglected.

In chapter seven, Kleinhans et al. report on their study of gender variations in mental health outcomes during the country’s first COVID-19 pandemic lockdown. The study focused on the differential influence of stress, fear, and worry on depression vulnerability by gender during the pandemic lockdown. The study discovered that fear of COVID-19 disease affected stress and depression levels in both genders, with women reporting more stress than males. This has significant implications for post-pandemic mental health interventions. It provides a chance to eliminate gender disparities in mental health care by delivering individualised care services, particularly during times of high stress.

South Africa’s reliance on coal-fired power has had a severe impact on climate, environmental health, and public health. In light of this, Irlam and colleagues explore the growing call for a transition to clean renewable energy that maximises socio-economic and local ecological benefits (chapter 8). The chapter addresses the healthcare sector’s contribution to environmental pollution and climate change, and argues that climate change will put more strain on South Africa’s already overburdened health system. The authors stress the role that health professionals can play in advocating for environmentally sustainable health care as part of global and local efforts towards greater climate justice and health equity, and the importance of educating health professionals. The chapter discusses some of the proposals for public health within the South African just transition movement, with a particular focus on the extremely polluted Highveld Priority Area in Mpumalanga.

Chapter nine examines the response of the Western Cape Department of Health to a sequence of catastrophic occurrences in the province (fires, floods, the COVID-19 pandemic, drought, and load shedding). Quintana et al. identify the key lessons learnt and provide a framework for strengthening the health sector’s response to climate change. Recommendations include the need for both provincial and national health departments to participate in climate fora in order to register the importance of building health-sector resilience to climate change; and an ongoing focus on health-system strengthening that improves system capacities and service redesign, with a focus on emergency services, primary health care, communications, surveillance, risk management, and disaster-planning capabilities.

In chapter 10, Walker and colleagues report on a training and capacity-building initiative to strengthen collaboration among eight Southern African countries in implementing public health emergency response strategies. The initiative enabled shared analysis of cross-border movement patterns; building neighbouring countries’ capacity to identify priority areas for such response planning; and strengthened relationships for communicating health risks and events. The project also sought to implement initiatives to strengthen cross-border and multi-sectoral communication; prioritise points of entry for cross-border co-ordination; map population movement patterns; and identify national and regional border health priorities.

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”.² In chapter 11, Ndlovu and colleagues examine the available health-information data sources in South Africa, with a particular focus on whether they strengthened during and after the acute phase of the COVID-19 pandemic. The chapter presents a repository of provincial and national data describing the broad status of the South African health system. Data were sourced primarily from national routine data sources, but also captured from major surveys and global reports, and include socio-demographic indicators and determinants, health-status indicators, and health-service indicators.

Conclusion

The collection of articles in this edition of the Review provides valuable insights into the potential benefits and drawbacks of the strategies employed to address the numerous challenges presented by the pandemic. Emerging lessons reference the importance of incorporating information from diverse sources to facilitate evidence-based decision making; the need to effectively and expeditiously manage and meet the information requirements of various end-users; the necessity of considering local contexts when formulating responses; the considerable value of collaboration across diverse sectors, and the adoption of a comprehensive approach that encompasses all segments of society. These findings provide significant contributions to inform South Africa’s transition towards a more sustainable long-term approach to managing COVID-19 and the development of its future pandemic preparedness response.

Ashnie Padarath and Themba L. Moeti