The Road to Universal Healthcare Coverage in the Face of COVID-19: South Africa's Struggles and Prospects

*Nelly Sharpley*

## **Abstract**

The COVID-19 pandemic has exposed the fragility of healthcare systems worldwide, especially in developing countries like South Africa. The country has been grappling with a long-standing struggle to achieve universal healthcare coverage, and the pandemic has brought to the fore the urgent need to address the disparities in healthcare access and outcomes. This paper explores South Africa's journey towards universal healthcare and the challenges and solutions it has encountered in the face of the COVID-19 pandemic. It discusses the impact of the pandemic on the country's healthcare system and highlights the inequities in access to care, especially among vulnerable populations. It also examines the policy responses implemented by the government to address these challenges, including the use of digital technology and community-based care. The paper concludes by emphasizing the need for sustained efforts to achieve universal healthcare in South Africa beyond the pandemic and the importance of global solidarity in this pursuit.

**Keywords:** universal healthcare, COVID-19, South Africa, healthcare disparities, policy responses

## **1. Introduction**

Universal healthcare, also referred to as universal health coverage (UHC), has been advocated by the World Health Organization (WHO) as the primary framework for healthcare provision [1]. UHC aims to ensure that individuals and communities have access to essential health services without facing financial hardships. It encompasses a wide range of high-quality healthcare services, including health promotion, prevention, treatment, rehabilitation, and palliative care.

The foundation of UHC can be traced back to the WHO's declaration in 1948, which recognized health as a fundamental human right and stressed the importance of affordable and timely access to comprehensive healthcare services for all individuals [2]. The ultimate goal of UHC is to remove financial barriers and guarantee universal access to healthcare, irrespective of an individual's socioeconomic status or geographic location. However, despite this declaration, South Africa currently lacks UHC and operates with two parallel healthcare systems: the private and public sectors, which coexist with each other.

Ensuring accessibility to healthcare remains a significant challenge in South Africa, particularly in rural areas where healthcare services are inadequate. Moreover, the public healthcare system faces difficulties in retaining healthcare professionals, exacerbating the existing disparities in care. Approximately 80% of the population relies on the public system, which receives government subsidies but suffers from underfunding and poor management. The country boasts over 400 public hospitals, managed at different levels by provincial health departments and municipal authorities, including regional hospitals and primary care clinics.

The healthcare system in South Africa is divided into two unequal parts: private and public. The private sector is renowned for its high-quality services, advanced medical technology, and well-equipped facilities, but is only accessible to those who can afford private health insurance or out-of-pocket payments. Private healthcare providers prioritize patients' satisfaction by providing shorter wait times and a higher standard of care due to better infrastructure and resources available in these facilities. However, the high cost of private healthcare in South Africa makes it inaccessible to a large portion of the population. On the other hand, the government-funded public healthcare system provides services either for free or at significantly subsidized rates, catering to the majority of South Africa's population who cannot afford private healthcare. Public healthcare facilities, including hospitals, clinics, and health centres, are widely available but often face challenges related to resource shortages, infrastructure deficiencies, and staff shortages. The public healthcare system serves a larger portion of the population, especially those without private health insurance, and is more accessible in rural and underserved areas. However, it also faces numerous challenges, including underfunding, overcrowding, and shortages of medical staff, equipment, and essential medicines resulting in longer waiting times, inadequate services, and sometimes compromised quality of care [3, 4]. According to Netshiswinzhe et al. [5], apartheid has had a significant impact on access to and utilization of healthcare services in South Africa. They discuss this in their article "Understanding the Influence of apartheid on Access and Utilization of healthcare services in South Africa" [6]. On the same view [7] also presents the challenges noted on SA public health system.

The significant disparities in healthcare quality between the private and public sectors contribute to unequal healthcare access based on socioeconomic status. Addressing these disparities requires comprehensive reforms, increased funding, improved management, and equitable distribution of resources to bridge the gap between the two systems, aiming for more equitable healthcare access and quality for all South Africans. It is imperative that the government takes immediate action to address the challenges faced by the public healthcare system to ensure that all South Africans have access to high-quality healthcare services, regardless of their socioeconomic status [8, 9]. Currently, moving closer to achieving UHC, South Africa is currently implementing healthcare system reforms through the establishment of a national health insurance (NHI) program. In parallel, South Africa introduced the Ideal Clinic framework in 2020 as a step towards UHC, with a focus on infrastructure, staffing, medication and supplies, administrative processes, and bulk supplies. The framework also emphasizes the adoption of relevant clinical policies, protocols, and guidelines, as well as collaboration with partners and stakeholders. These initiatives aim to enhance healthcare delivery and bring South Africa closer to achieving UHC, although challenges and disparities between the two healthcare systems persist [10, 11].

*The Road to Universal Healthcare Coverage in the Face of COVID-19: South Africa's Struggles... DOI: http://dx.doi.org/10.5772/intechopen.114160*

Public healthcare system is discussed by Rispel et al. [12] in their article "Analysis of the ideal clinic programme as a platform for the delivery of quality health services in South Africa: Case study of primary healthcare in KwaZulu-Natal and as noted above, the study highlights prospects and problem.

When the COVID-19 pandemic engulfed the world, the healthcare system in South Africa was already overwhelmed due to the burden of diseases and its direct impact on socioeconomic inequalities within the country [13]. This situation exacerbated the challenges faced by the majority of disadvantaged populations residing in rural areas. Although the country has made efforts to provide accessible primary healthcare through community-based clinics and centers, there has been a failure to effectively address the underlying socioeconomic inequalities within the system [14].

Consequently, in many areas, the process of healthcare coverage became superficial, resulting in a lack of access to necessary services and treatment. Even though the physical infrastructure of the healthcare system may be visible, in some cases, it does not meet the requirements for effective healthcare provision. As a consequence, the expansion of healthcare coverage became an unattainable goal, further widening health inequalities [14]. The COVID-19 pandemic has starkly highlighted and exacerbated the pre-existing inequalities in South Africa, particularly in rural areas. As Bank and Sharpley [15] have pointed out, the rural poor have been subjected to what they call "Ukuvala ISango"—a total closure of the gate to healthcare access and basic services. In the face of this crisis, rural populations have been left to fend for themselves, with no screening or testing available to them. Clinics have been closed, rendering primary healthcare an illusory prospect for most rural residents, especially those with chronic conditions. Only the affluent working class could afford medical protection against the pandemic, pushing the rural poor even further to the margins. This is a dire situation that the pandemic exposed that demands immediate attention and action. At the time of vaccination, there was a significant mobilization of resources to get the rural population vaccinated. Mobile clinics and temporary stations were erected to ensure that everyone had access to the vaccine. However, it is concerning that many rural people reported feeling coerced into taking the vaccine. This is unacceptable as every individual has the right to make their own informed decisions about their health without any undue pressure. No one should be threatened with being denied access to essential services, basic necessities, or social grants for choosing not to take the vaccine [15].

### **2. Literature**

#### **2.1 South African health care system during COVID-19**

Gebremeskel et al. [16] asserted that health system resilience was defined as the ability of health actors, institutions, and populations to establish absorption, adaptation, accessibility, and transformation capabilities to prepare for surprises in the health system and respond effectively to disruptions. Health system resilience is openly related to health system governance, that is, resilience depends on the decisions of groups and individuals as they make change, monitor, and enforce the rules that direct the health system. The COVID-19 pandemic has exposed the long-standing structural causes of health inequalities. There are anxieties that public health policies could amplify the harmful effects of these inequalities unless vigilant efforts are made to mainstream these social weaknesses into public health systems [16].

Masuku et al. [17] displays that child and youth caregivers were exposed to poor mental health because they experienced anxiety, insecurity, and stress. Moreover, these workers have faced challenges when working under the so-called new normal, which was introduced as part of a non-pharmaceutical response to contain the spread of COVID-19 [17].

According to Banda Chitsamatanga and Malinga [18], the hasty spread of the COVID-19 leads to panic around the world and calling into question the preparedness of public health systems to deal with it. This has undoubtedly made the word COVID-19 a new slogan. Banda Chitsamatanga and Malinga [18] distinguished that despite economic inequality and differential income status, the pandemic has exposed that there are ingrained problems in overburdened public health systems. In addition, the situation is further projected and exacerbated by primary socioeconomic issues identical to poverty, unemployment, inequality, slow economic development, inadequate water and sanitation, and food insecurity, which have made it challenging to cope with the pandemic.

Access to contraception became a challenge due to lockdown, reduced mobility, reduced availability of public transport, and the closure of non-essential retail outlets and youth centers also limited young people's access to contraception. Hence, a lack of these goods can lead to risky sexual practices and unwanted pregnancies [19], both of which were long-standing problems before lockdowns were imposed in response to COVID-19 [20]. For people living with HIV, condom shortages can increase the likelihood of HIV transmission. Additionally, fear of contracting SARS-CoV-2 discourages individuals from attending public clinics [21]. Therefore, there is a need to strike a balance between directly responding to the COVID-19 pandemic and respecting human rights and supporting children and young people, mainly vulnerable groups, to ensure that food, education, and counseling services are available. More generally, the COVID-19 public health crisis highlights the importance of offering fiscal support to improve healthcare systems.

Consequently, there is vigorous evidence of medical plants in the use of both traditional and biomedical products and services in South Africa [22], and traditional health practitioners are regularly the first healthcare approach for patients when they become ill. Some people feel that the solution to COVID-19 would come through traditional health practitioners rather than biomedical interventions [23], while others fear infection of COVID-19 in healthcare settings, suggesting that the focus on safe access to healthcare services is crucial.

#### **2.2 Challenges in coping with COVID**

Gebremeskel et al. [16] asserted that health system resilience was defined as the ability of health actors, institutions, and populations to establish absorption, adaptation, accessibility, and transformation capabilities to prepare for surprises in the health system and respond effectively to disruptions. Health system resilience is openly related to health system governance, that is, resilience depends on the decisions of groups and individuals as they make changes, monitor, and enforce the rules that direct the health system. The COVID-19 pandemic has exposed the long-standing structural causes of health inequalities. There are anxieties that public health policies could amplify the harmful effects of these inequalities unless vigilant efforts are made to mainstream these social weaknesses into public health systems [16].

Furthermore, Masuku et al. [17] specified that child and youth caregivers were exposed to poor mental health because they experienced anxiety, insecurity, and stress. Moreover, these workers have faced challenges when working under the socalled new normal, which was introduced as part of a non-pharmaceutical response to contain the spread of COVID-19 [17].

#### *The Road to Universal Healthcare Coverage in the Face of COVID-19: South Africa's Struggles... DOI: http://dx.doi.org/10.5772/intechopen.114160*

According to Banda Chitsamatanga and Malinga [18], the hasty spread of COVID-19 leads to panic around the world and calls into question the preparedness of public health systems to deal with it. This has undoubtedly made the word COVID-19 a new slogan. Banda Chitsamatanga and Malinga [18] distinguished that despite economic inequality and differential income status, the pandemic has exposed that there are ingrained problems in overburdened public health systems. In addition, the situation is further projected and exacerbated by primary socioeconomic issues identical to poverty, unemployment, inequality, slow economic development, inadequate water and sanitation, and food insecurity, which have made it challenging to cope with the pandemic.

While countries implement public health measures to lessen transmission of SARS-CoV-2, young girls and women, people who identify as LGBTI, people engaged in sex work are more likely to become victims of police brutality [24]. Access to contraception became a challenge due to lockdown, reduced mobility, reduced availability of public transport, and the closure of non-essential retail outlets and youth centers also limited young people's access to contraception. Hence, a lack of these goods can lead to risky sexual practices and unwanted pregnancies [19], both of which were long-standing problems before lockdowns were imposed in response to COVID-19 [20]. For people living with HIV, condom shortages can increase the likelihood of HIV transmission. Additionally, fear of contracting SARS-CoV-2 discourages individuals from attending public clinics [21]. Therefore, there is a need to strike a balance between directly responding to the COVID-19 pandemic and respecting human rights and supporting children and young people, mainly vulnerable groups, to ensure that food, education, and counseling services are available. More generally, the COVID-19 public health crisis highlights the importance of offering fiscal support to improve healthcare systems.

Consequently, there is vigorous evidence of medical plants in the use of both traditional and biomedical products and services in South Africa [22], and traditional health practitioners are regularly the first healthcare approach for patients when they become ill. Some people felt that the solution to COVID-19 would come through traditional health practitioners rather than biomedical interventions [23], others fear infection of COVID-19 in healthcare settings, suggesting that the focus on safe access to healthcare services is crucial.

## **3. Methodology**

The methodology was partly an ethnographic mixed methods approach with both qualitative and quantitative data tools used. Data was collected through situational observations, dialogs and the use of a semi-structured questionnaire processed through the use of epicollect5 data collection software, for 1800 households from 10 rural local municipalities in the rural Eastern Cape from the former Transkei side. Quantitative Data was analyzed through the use of SPSS and the qualitative data was coded and thematically arranged cross-tabularised and matched to/against the quantitative data. The Eastern Cape is a province that is predominantly rural and most of its population depends on public healthcare provisioning. The map below shows the areas that were covered in the study we conducted on COVID-19 and vaccine hesitancy, which was a built-up study from the same rural municipalities that participated in the EC study on Covid and rural South Africa, both utilized in this paper. The red dots represent rural settlements in the study under the selected local municipalities mentioned (**Figure 1**).

**Figure 1.** *Rural settlements where participants were drawn.*

## **4. Data presentation**

The data is presented to reflect the demographic characteristics as well as the below is the presentation of data drawn from the three phases of the COVID-19 research study project conducted in the same local municipalities concurrently. The selected data speaks to the objectives of this paper, which is to reflect on the road to universal healthcare in the face of COVID-19 and SA.

**Figures 2–4** represent the population profile of the participants in the study, their gender, education and employment.

**Figure 2** shows most of the participants from some settlements being females, even though male representation is relatively fair. The explanation for this is that although the research was open for both males and females to participate, since the participants were captured from their homes, predominantly it was noticed that women were the ones mostly available in the homes. The reason for that can be listed among others, as the prevalence of female-headed households, the flexibility that women have in participating in research studies as this research observed voluntary participation and females being the highest population group in the areas.

**Figure 3** shows that the majority of the participants in the COVID and vaccination study we did in rural South Africa had none to minimum education, which does not guarantee any significant employment or income.

**Figure 4**, the text describes the employment status of the participants and highlights that the majority of people in rural settlements are not employed. As explained in the background, the rural population, which makes up the highest proportion of the South African population, relies on public resources for healthcare.

Data Presenting COVID-19 Experience in EC—closure of clinics and long queues of people looking to be severed for their health needs and only to be turned back home without any assistance (see **Figures 5**–**7**).

*The Road to Universal Healthcare Coverage in the Face of COVID-19: South Africa's Struggles... DOI: http://dx.doi.org/10.5772/intechopen.114160*

**Figure 2.** *Population profile.*

**Figure 3.** *Educational level of participants.*

## **5. Discussion**

South Africa has grappled with challenges in achieving universal healthcare, primarily due to the stark disparities between its private and public healthcare sectors [11]. The emergence of the COVID-19 pandemic exacerbated existing health disparities, disproportionately affecting the rural poor and underserved communities, further hindering their access to quality healthcare services [15]. The reality of healthcare provision in South Africa, especially in rural areas, falls short of the envisioned standards of universal healthcare [15]. The COVID-19 pandemic exacerbated existing healthcare inequalities, particularly in terms of affordability, accessibility,

**Figure 4.** *Employment status of participants.*

#### **Figure 5.**

*Clinic closed after staff tested positive with COVID-19. Nursing staff at Motherwell NU2 clinic stand outside the main gate. The clinic was closed after staff members tested positive for COVID-19. Photo: Joseph Chirume, GroundUp. Accessed 17.07.23. http://www.hsrc.ac.za/en/review/hsrc-review-nov-2020/ health-care-during-covid19.*

and inadequate infrastructure [15]. During the pandemic, rural clinics and healthcare centres were shuttered, resulting in limited access and inadequate compliance with COVID-19 regulations [15]. Nurses lacked adequate training to handle COVID-19 cases, leading to referrals to larger hospitals [15]. The dual healthcare system in South Africa, comprising private and public sectors, poses challenges in achieving equitable healthcare access, especially for rural communities [4, 11]. Access to quality healthcare resources during the pandemic favored those with financial means for private

*The Road to Universal Healthcare Coverage in the Face of COVID-19: South Africa's Struggles... DOI: http://dx.doi.org/10.5772/intechopen.114160*

#### **Figure 6.**

*Patients sent away due to clinic closure after 11 nurses died of COVID-19 infection. Dozens of patients were sent away in May 2020 after the eastern cape Department of Health shut down Zwide Clinic in Port Elizabeth following the death of a nurse and 11 other staff members testing positive for the coronavirus. Photo: Mkhuseli Sizani, GroundUp. Accessed 17.07.23. http://www.hsrc.ac.za/en/review/hsrc-review-nov-2020/ health-care-during-covid19.*

#### **Figure 7.**

*Picture showing most clinics and community healthcare centres in the rural areas closed as well as one major district hospital ordered to close.*

healthcare services, while rural populations faced barriers such as affordability and geographical access [12, 22]. Efforts to bridge this gap have introduced primary healthcare systems to deliver essential services to marginalized communities but have been constrained by financial strain and inadequate infrastructure [3, 25]. Initiatives like the "ideal clinic framework" aimed to establish high-quality primary healthcare services but faced limited coverage and implementation challenges [12, 26].

Discourse on a national health insurance system has been ongoing to provide affordable healthcare access to all citizens, but actualization remains elusive, leaving economically disadvantaged communities vulnerable [7, 9].

South Africa has yet to achieve universal healthcare coverage, and the existing dual healthcare in the country system perpetuates healthcare disparities. The COVID-19 pandemic highlighted the unequal access to quality healthcare, especially for marginalized communities. Policy reforms and a comprehensive approach are necessary to address these challenges and move towards equitable healthcare access for all South Africans [27]. The COVID-19 pandemic exacerbated these existing disparities, particularly impacting the rural poor's access to healthcare services [15]. The closure of rural clinics and healthcare centres during the pandemic worsened the situation, leaving vulnerable communities without essential healthcare services [15]. Nurses lacked proper training to manage COVID-19 cases, resulting in referrals to urban hospitals and further limiting rural populations' access to adequate care [15]. Rural communities faced multifaceted challenges during the pandemic, including limited transportation options to reach healthcare facilities, non-operational clinics, and a lack of adherence to COVID-19 regulations due to inadequate infrastructure [22]. These challenges disproportionately affected the rural poor, hindering their ability to seek timely healthcare, including COVID-19 screening and essential medical services [28]. Despite efforts to bridge the gap between private and public healthcare sectors, initiatives such as the "ideal clinic framework" faced implementation challenges and limited coverage, especially in rural areas [12, 26]. Discussions around a national health insurance system aimed at providing affordable healthcare for all citizens remain unresolved, leaving economically disadvantaged communities without proper coverage [9].

## **6. Conclusion and recommendations**

In order to advance towards universal healthcare, South Africa needs to conduct a thorough policy review to evaluate the feasibility of implementation. Reforms aimed at providing equitable healthcare are crucial to ensure that the fundamental right to health is upheld for the entire population. Universal health coverage (UHC) plays a critical role in global health security. It can improve the capacity for health security, including preventing and controlling emerging diseases. Inadequate UHC in one country may cause population movements across borders to seek care in neighboring countries. UHC is a major cornerstone of the UN Sustainable Development Goals. It is vital for strengthening health systems and enhancing countries' future health security. Although the relationship between UHC and global health security is complex, it is widely recognized that they are interdependent and mutually reinforcing. Strengthening health systems is the most promising mechanism for benefiting both UHC and global health security. This exposition emphasized in this conclusion has been expressed by several scholars [29, 30]. Therefore, achieving UHC is not only a matter of health equity but also a critical component of global health security.

*The Road to Universal Healthcare Coverage in the Face of COVID-19: South Africa's Struggles... DOI: http://dx.doi.org/10.5772/intechopen.114160*

## **Author details**

Nelly Sharpley The University of KwaZulu-Natal, Durban, South Africa

\*Address all correspondence to: sharpleyn@ukzn.ac.za

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 12**
