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South African Health Review Key Findings 2021


The Health Systems Trust, in collaboration with the Health Economics and AIDS Research Division (HEARD), a unit of the University of KwaZulu-Natal, are proud to release the key findings of the 2021 edition of the South African Health Review.

This special edition, entitled, COVID-19, what have we learnt? documents the South African health sector's response to COVID-19; provides examples of innovations, best practises, and collaboration; and assesses the impact of COVID-19 on vulnerable populations. Overall, the publication is a repository of valuable information, including lessons for developing resilient health systems capable of responding to public health emergencies.

The publication's contents cover a wide range of topics, from assessing the government's response to COVID-19 and efforts to balance lives and livelihoods, to investigating the impact of COVID-19 on human resources for health and vulnerable populations, and documenting good practises and promising innovations.

To access the Chapters at a Glance please click here.

Some of the key messages from this year's edition are as follows:

The Review notes that while Government's swift and decisive action in the form of a risk-adjusted strategy delayed the peak in COVID-19 cases, and saved lives, complete lockdowns have shown to be a blunt tool which have vast economic and socio-economic side-effects that disproportionately affects the poor and other vulnerable populations. 

The pandemic has had devastating socio-economic costs; an estimated 2.8 million South Africans have lost their jobs. South Africa's budgetary and Public Finance Management systems channelled the allocation of more than R20 billion to the health sector COVID-19 response and an additional R100 billion has been spent on income support through new social grants and TERS benefits.

COVID-19 has placed an even greater strain on South Africa's overburdened and under-resourced health system and has stymied the progress the country has made in strengthening health systems towards achieving universal health coverage.  It has also disrupted access to health care for chronic conditions, including non-communicable diseases, testing, treatment initiation, and continuity of care for HIV and TB, as well as for sexual and reproductive health services, due to both travel restrictions and the re-orientation of healthcare services to respond to the pandemic. 

Overall, findings show that the COVID-19 pandemic placed an additional burden on already resource-constrained healthcare facilities, with nurses enduring shortages of basic resources, rapid depletion and delayed restocking of COVID-19-related equipment, and additional strain due to staff shortages. Healthcare workers also experienced daily dilemmas and internal conflicts associated with the pandemic, which affected their health and well-being, and their ability to deliver services.  

The importance of taking a community-based approach to finding more sustainable and cost-effective methods of delivering services at the primary care and community levels has been consistently emphasised by chapters. In the current COVID-19 pandemic, the role of community health workers (CHWs) has expanded from the usual public health programme and health promotion support at the community level to include support for a critical community testing and screening component while still carrying out their previous community health worker responsibilities, highlighting how critical the role of CHWs has been in responding to this pandemic.

There has been an overall increase in maternal deaths, stillbirths and perinatal mortality.  Rural provinces experienced increased pressure on their services due to pregnant women migrating from metropolitan areas back to their homes; and metropolitan areas were inundated with severe COVID-19-specific conditions, leading to an increased burden in these areas and an inability to manage routine emergencies.

In addition, the predominant focus on adult-COVID-19 care meant that children's needs were overlooked leading to significant disruptions of routine child health services, gaps in immunisation and HIV testing and treatment, and a failure to put systems in place to address child hunger, care and protection. It is therefore vital that children's best interests are prioritised in government's response and recovery plans.

Government has not been sufficiently disability-inclusive in its management of the pandemic and the vaccination programme, which has deepened the multiple layers of vulnerability and challenges for persons with disabilities who are at heightened risk of contracting the virus, not only because of underlying condition, but also due to contextual barriers. 

The response to the COVID-19 pandemic has also accelerated action in a number of previously difficult areas. There has been progress in developing reporting systems that combine data from both the public and private sectors; there are promising examples of intersectoral collaboration, public-private partnerships, innovative joint ventures and examples of providing rehabilitation services under strict lockdown conditions.

The Review will be formally launched in mid-2022 and will be available in both electronic and hard copy format. 

The Health Systems Trust wishes to acknowledge the Johnson & Johnson Foundation for the grant funding that made the 2021 edition of the South African Health Review possible. For more on the Johnson & Johnson Foundation please go to


The South African Health Review (SAHR) is an accredited peer-reviewed publication. Now in its 24th edition, the aims of the Review are to advance the sharing of knowledge, to feature critical commentary on policy implementation, and to offer empirical understanding towards improving South Africa's health system. The Review is recognised as one of the most authoritative sources of commentary on the South African health system. It is widely used in teaching public health at undergraduate and postgraduate level in South Africa, and by scholars, donors, journalists, policy makers and policy implementers at various levels of the health system.   

Chapters for the Review comprise a mix of specifically commissioned work reflecting on core health systems issues, as well as issues of particular importance, with findings from topical research. Authors comprise subject specialists, assisted wherever feasible by less-experienced researchers as a means of capacity development. Contributors include those working in the formal public health sector, parastatal organisations, scientific councils, non-governmental organisations, academia, and bilateral and multilateral support agencies.


The Health Systems Trust (HST) is a leading role-player in the South African public health arena, focusing on health systems strengthening, research, and strategic support in the implementation of priority health programmes. Established in April 1992, on the brink of democracy in South Africa, HST has played a significant role in the evolution of the national health system. Today our strength lies in the knowledge, insight and experience we harness through synergising our research and implementation outputs towards a healthy life for all.