Abstract Introduction Approach Results Discussion Acknowledgements References About the Author(s) Juliet Nyasulu School of Clinical Medicine, Division of Community Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa AFRIQUIP, Health Systems Strengthening, Johannesburg, South Africa Himani Pandya School of Clinical Medicine, Division of Community Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Citation Nyasulu J, Pandya H. The effects of coronavirus disease 2019 pandemic on the South African health system: A call to maintain essential health services. Afr J Prm Health Care Fam Med. 2020;12(1), a2480. https://doi.org/10.4102/phcfm.v12i1.2480 Note: Special Collection: COVID-19.

Short Report The effects of coronavirus disease 2019 pandemic on the South African health system: A call to maintain essential health services Juliet Nyasulu, Himani Pandya Received: 24 Apr. 2020; Accepted: 04 June 2020; Published: 22 July 2020 Copyright: © 2020. The Author(s). Licensee: AOSIS. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract South Africa had its first coronavirus disease 2019 (COVID-19) case on 06 March 2020 in an individual who travelled overseas. Since then, cases have constantly increased and the pandemic has taken a toll on the health system. This requires extra mobilisation of resources to curb the disease and overcome financial loses whilst providing social protection to the poor. Assessing the effects of COVID-19 on South African health system is critical to identify challenges and act timely to strike a balance between managing the emergency and maintaining essential health services. We applied the World Health Organization (WHO) health systems framework to assess the effects of COVID-19 on South African health system, and proposed solutions to address the gaps, with a focus on human immunodeficiency virus (HIV) and expanded programme on immunisation (EPI) programmes. The emergence of COVID-19 pandemic has direct impact on the health system, negatively affecting its functionality, as depletion of resources to curb the emergency is eminent. Diversion of health workforce, suspension of services, reduced health-seeking behaviour, unavailability of supplies, deterioration in data monitoring and funding crunches are some of the noted challenges. In such emergencies, the ability to deliver essential services is dependent on baseline capacity of health system. Our approach advocates for close collaboration between essential services and COVID-19 teams to identify priorities, restructure essential services to accommodate physical distancing, promote task shifting at primary level, optimise the use of mobile/web-based technologies for service delivery/training/monitoring and involve private sector and non-health departments to increase management capacity. Strategic responses thus planned can assist in mitigating the adverse effects of the pandemic whilst preventing morbidity and mortality from preventable diseases in the population. Keywords: COVID-19 pandemic; WHO health systems framework building blocks; health systems; essential services; HIV; EPI. Introduction In South Africa, since March 06, when the first coronavirus disease 2019 (COVID-19) case was reported, cases have increased to over 188 000 at the time of writing this article.1 This pandemic has called for extra mobilisation of resources to curb the disease and overcome financial loses whilst providing social protection to the poor.2 For decades, the South African health system has shouldered a quadruple burden of diseases (much of which is preventable), with mother and child health indicators far from accepatable targets.3,4 The South African primary healthcare provides both curative and preventive health services. These include under-five child health services, such as growth monitoring and expanded programme on immunisation (EPI); reproductive health services such as family planning, cervical and breast cancer screening, antenatal, labour and postnatal care services; chronic disease care for both communicable and non-communicable diseases including human immunodeficiency virus (HIV) services; and many other health promotion, preventative and curative services.5 It is concerning that out of 7.7 million HIV-positive people living in South Africa, about 4.9 million people are on antiretroviral treatment (ART), with one-third (1.6 million) not virally suppressed.6 The current evidence indicates that those virally suppressed are not at higher risk. However, in addition to 1.6 million, we do not know about the other 2 million not on ART, who probably will be at higher risk of severe COVID-19 infection.6,7 South Africa has existing antiretroviral (ARV) and vaccine stock-out challenges because of supply chain constraints.8,9,10,11 In addition, gaps have been identified around low routine immunisation coverage resulting in outbreaks of vaccine preventable diseases, such as measles, in South Africa.12 Anecdotal reports show that there is a decline in access to ART from March 2020 by those already initiated on ART. For example, some districts supported by Right to Care (RTC), a President’s Emergency Plan for AIDS Relief (PEPFAR) partner for Gauteng Province, show increasing numbers of missed appointments to collect ART.13 Similarly, EPI and other essential services are also likely to be affected. Fear of contracting COVID-19, the physical distancing policy and a shift in focus of service providers from basic essential services to COVID-19 pandemic demands may be the reasons for the decline in access to essential services.14 Emergence of the COVID-19 pandemic risks the worsening of existing gaps and increasing deaths as shown in the previous Ebola outbreaks.15,16 The resilience of health system to timely adapt and strike a balance between maintaining routine services and coping with the pandemic is crucial to mitigate the damage.17 Currently, there is a rapid and overwhelming increase in strain on the health system because of COVID-19, overstretching the capacity of healthcare workers to operate effectively.18,19 This article looks at the possible effects of COVID-19 pandemic on the South African health system and proposes possible solutions to maintain the delivery of essential health services whilst fighting the pandemic, with a specific focus on HIV and EPI. We believe that maternity care, child care (e.g. immunisation) and HIV services stand out as the most critical markers and a proxy for the strength of a health system, particularly in the context of South Africa.6,8,12 Resilience of a health system is indicated by its ability to offer basic healthcare services to pregnant women, children and people with HIV. These groups are comparatively more vulnerable and contribute to a high burden of morbidity and mortality at a population level. Lessons from previous epidemics such as Ebola have shown that when there is a threat to a health system, these groups are affected first and to a higher extent.16 Moreover, because of our experience and expertise in working with HIV and immunisation, we selected them as priority services and focus of this article. Approach We applied the World Health Organisation (WHO) health systems framework and its six building blocks to assess how COVID-19 pandemic has affected the South African health system (Figure 1).20 FIGURE 1: Conceptual framework (based on World Health Organization building blocks of a health system). Using the documented existing service delivery gaps, we analysed EPI and HIV programmes as examples of priority essential health services to be maintained by South Africa during this emergency period.6,8,18 In addition, solutions to strike a balance between responding to COVID-19 pandemic and maintenance of these essential services are proposed. Ethical consideration This article followed all ethical standards for a research without direct contact with human or animal subjects. Results We applied the WHO health systems framework to highlight strengths and gaps in the EPI and HIV service delivery system and explain how these are affected with the emergence of the COVID-19 pandemic. We have also proposed possible solutions on how to deal with these challenges. The questions raised in the above conceptual framework do not specifically direct our analysis; rather, they serve as a generic guideline for consideration by health managers and stakeholders in order to maintain primary health services during a pandemic. Table 1 summarises these gaps and possible solutions to maintain essential service delivery, with a focus on HIV and EPI. TABLE 1: Health system risks posed by coronavirus disease 2019 and possible solutions to maintain essential services (according to the World Health Organization health systems framework). Discussion The emergence of the COVID-19 pandemic has put great burden on the health system, negatively affecting its functionality. We propose the WHO health systems framework as an approach for assessing and prioritising services by health systems to strike a balance between the responses to COVID-19 pandemic and delivery of quality essential healthcare services, with a focus on EPI and HIV programmes. Firstly, representation and close collaboration between the COVID-19 and the essential services teams at all levels are recommended. These teams together will need to identify priority essential services within the two programmes and decide which services are to be continued, postponed or suspended.18 At this time, identification of how the emergency is affecting the health system and which geographic areas and vulnerable groups should be prioritised are critical.18,30 Application of the WHO health systems building blocks will provide a systematic and comprehensive approach to the identification of these gaps.20 The next step is to identify and implement solutions to address the gaps worsened or caused by the COVID-19 emergency response. For instance, the redeployment of health workforce, coupled with others being infected with COVID-19, depleted the already existing shortage.19 Therefore, considering task shifting, integration of services, utilisation of senior students, tapping from NGO partners and government workforce outside the Department of Health would alleviate the health workforce shortage.18,19,20,21,22,23,24 The most important task is to provide support to the available health workforce in different aspects needed.31 Admittedly, the COVID-19 physical distancing currently advocated for puts HIV-positive individuals and parents in a dilemma to defer routine appointments, worsening the current gaps in HIV/EPI programme.21 Therefore, in order to ensure positive health-seeking behaviour and adherence to care, there is a need to maintain population’s trust in the capacity of the health system to safely meet essential needs and to control infection risk in health facilities.18 This requires training of health service providers in providing essential services with extra safety to control the spread of COVID-19,18 accompanied by communication with the users and reassurance of access and safety of health services. In times of such pandemics, it is important to ensure that the vulnerable communities including the poor and the elderly have the ability to access these essential services.18,30 Furthermore, existing gaps in immunisation and HIV services including stock-outs have been established, which can worsen when dealing with the COVID-19 pandemic.8,9 We therefore propose service delivery approaches that do not attract crowds like CCMDD and outreach services.18,22,23 We also suggest the need to minimise relying on manual operations and paper-based service delivery and monitoring, and utilise information technology and web-based platforms to monitor and conduct its routine operations.26,32 End-user monitoring of the supply chain by patients and civil society has the potential to increase transparency and complement public sector monitoring systems.8 In conclusion, the resilience of the health system is a critical determinant of how a country responds to a pandemic.33 In emergencies like COVID-19, the ability of a health system to deliver essential services is dependent on the existing burden and baseline capacity of the health system. The existing high disease burden would put the South African health system in a fragile state to cope with the pandemic if timely adaptation actions are not taken. The approach proposed in this article, about using WHO building blocks to identify existing gaps, challenges and possible solutions, can be adopted by other low- and middle-income settings to identify priority actions in order to strike a balance between attending to a pandemic and simultaneously maintaining essential services. The authors envisage that applying these principles during such pandemics will lead to informed health systems decisions in striking a balance between emergency response and essential health service delivery, and maintaining of curative and preventive essential health services, which in turn will reduce morbidity and mortality from preventable and treatable diseases. Acknowledgements The authors would like to thank Prof. Susan Goldstein for her input in conceptualising the health systems gaps. Competing interests The authors have declared that no competing interests exist. Authors’ contributions J.N. conceptualised the study and wrote the first draft. J.N. and H.P. were both involved in the writing of the manuscript and approval of the final version. Funding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Data availability statement Data sharing is not applicable to this article as no new data were created or analysed in this study. Disclaimer The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. References National Institute of Communicable Diseases (NICD). South Africa certified polio-free [homepage on the Internet]. National Institute of Communicable Diseases (NICD); c2019 [cited 2020 July 05]. 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doi: 10.7189/jogh.13.06006

31. Priority setting during the COVID-19 pandemic: going beyond vaccines
Iestyn Williams, Beverley Essue, Elysee Nouvet, Lars Sandman, S Donya Razavi, Mariam Noorulhuda, Susan Goold, Marion Danis, Godfrey Biemba, Julia Abelson, Lydia Kapiriri
BMJ Global Health  vol: 6  issue: 1  first page: e004686  year: 2021  
doi: 10.1136/bmjgh-2020-004686

32. Companion restrictions in the emergency department during COVID-19: physician perceptions from the Western Cape, South Africa
Lauren E Wiebe, Helle Molsted Alvesson, Willem Stassen
BMJ Open  vol: 13  issue: 5  first page: e070982  year: 2023  
doi: 10.1136/bmjopen-2022-070982

33. Sociability, Social Isolation, and Social Interaction During the First Months of COVID-19 Pandemic: a Qualitative Analysis of Brazilian, Finnish, and American Adults
Juliene Madureira Ferreira, Elisa A. Merçon-Vargas, Allegra J. Midgette
Trends in Psychology  vol: 31  issue: 4  first page: 924  year: 2022  
doi: 10.1007/s43076-022-00172-9

34. AIDS and COVID-19 in southern Africa
Arnau van Wyngaard, Alan Whiteside
African Journal of AIDS Research  vol: 20  issue: 2  first page: 117  year: 2021  
doi: 10.2989/16085906.2021.1948877

35. Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990–2050
Angela E Micah, Ian E Cogswell, Brandon Cunningham, Satoshi Ezoe, Anton C Harle, Emilie R Maddison, Darrah McCracken, Shuhei Nomura, Kyle E Simpson, Hayley N Stutzman, Golsum Tsakalos, Lindsey E Wallace, Yingxi Zhao, Rahul R Zende, Cristiana Abbafati, Michael Abdelmasseh, Aidin Abedi, Kedir Hussein Abegaz, E S Abhilash, Hassan Abolhassani, Michael R M Abrigo, Tara Ballav Adhikari, Saira Afzal, Bright Opoku Ahinkorah, Sepideh Ahmadi, Haroon Ahmed, Muktar Beshir Ahmed, Tarik Ahmed Rashid, Marjan Ajami, Budi Aji, Yonas Akalu, Chisom Joyqueenet Akunna, Hanadi Al Hamad, Khurshid Alam, Fahad Mashhour Alanezi, Turki M Alanzi, Yosef Alemayehu, Robert Kaba Alhassan, Cyrus Alinia, Syed Mohamed Aljunid, Sami Almustanyir Almustanyir, Nelson Alvis-Guzman, Nelson J Alvis-Zakzuk, Saeed Amini, Mostafa Amini-Rarani, Hubert Amu, Robert Ancuceanu, Catalina Liliana Andrei, Tudorel Andrei, Blake Angell, Mina Anjomshoa, Carl Abelardo T Antonio, Catherine M Antony, Muhammad Aqeel, Jalal Arabloo, Morteza Arab-Zozani, Timur Aripov, Alessandro Arrigo, Tahira Ashraf, Desta Debalkie Atnafu, Marcel Ausloos, Leticia Avila-Burgos, Asma Tahir Awan, Getinet Ayano, Martin Amogre Ayanore, Samad Azari, Gulrez Shah Azhar, Tesleem Kayode Babalola, Mohammad Amin Bahrami, Atif Amin Baig, Maciej Banach, Nastaran Barati, Till Winfried Bärnighausen, Amadou Barrow, Sanjay Basu, Bernhard T Baune, Mohsen Bayati, Habib Benzian, Adam E Berman, Akshaya Srikanth Bhagavathula, Nikha Bhardwaj, Pankaj Bhardwaj, Sonu Bhaskar, Sadia Bibi, Ali Bijani, Virginia Bodolica, Nicola Luigi Bragazzi, Dejana Braithwaite, Nicholas J K Breitborde, Alexey V Breusov, Nikolay Ivanovich Briko, Reinhard Busse, Lucero Cahuana-Hurtado, Emily Joy Callander, Luis Alberto Cámera, Carlos A Castañeda-Orjuela, Ferrán Catalá-López, Jaykaran Charan, Souranshu Chatterjee, Soosanna Kumary Chattu, Vijay Kumar Chattu, Simiao Chen, Arrigo Francesco Giuseppe Cicero, Omid Dadras, Saad M A Dahlawi, Xiaochen Dai, Koustuv Dalal, Lalit Dandona, Rakhi 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36. Identifying the preparedness components in COVID-19
Pooneh Maziar, Ali Maher, Khalil Alimohammadzadeh, Mehrnoosh Jafari, Seyed Mojtaba Hosseini
Journal of Education and Health Promotion  vol: 11  issue: 1  first page: 385  year: 2022  
doi: 10.4103/jehp.jehp_28_22

37. Sexual Risk Behaviors Among Youth in Soweto, South Africa During the COVID-19 National Lockdown
Mamakiri Mulaudzi, Peace Kiguwa, Campion Zharima, Kennedy Otwombe, Khuthadzo Hlongwane, Janan J. Dietrich
Sexual Medicine  vol: 10  issue: 2  first page: 100487  year: 2022  
doi: 10.1016/j.esxm.2021.100487

38. Strategies and challenges for maintaining the continuity of essential health services during a pandemic: a scoping review
Najibeh Khoshmaram, Kamal Gholipour, Mostafa Farahbakhsh, Jafar Sadegh Tabrizi
BMC Health Services Research  vol: 25  issue: 1  year: 2025  
doi: 10.1186/s12913-025-12812-8

39. The Ripple Effect of COVID‐19: How Lockdown Regulations Shaped Antiretroviral Therapy Initiation Among People Living With HIV in Johannesburg
N. Nkadimeng, L. Makhado, O. P. Netshisaulu
Nursing & Health Sciences  vol: 27  issue: 3  year: 2025  
doi: 10.1111/nhs.70235

40. Enhancing Routine Childhood Vaccination Uptake in the Cape Metropolitan District, South Africa: Perspectives and Recommendations from Point-of-Care Vaccinators
Elizabeth O. Oduwole, Christina A. Laurenzi, Hassan Mahomed, Charles S. Wiysonge
Vaccines  vol: 10  issue: 3  first page: 453  year: 2022  
doi: 10.3390/vaccines10030453