On the first day of January 2020, only a few people knew about a worrying new infection in Wuhan, China. By the end of the year, the infection had swept across the globe, causing over 1.6 million confirmed deaths (actual deaths will be significantly higher).

On the one hand, the story of the coronavirus disease 2019 (Covid-19) over the past 12 months, was one of massively disruptive lockdowns and people dying in hospitals that were put under immense strain. On the other hand, it was also a year of remarkable scientific achievement. By the end of November preliminary – but nevertheless compelling – data had shown that three different vaccines offer protection against Covid-19. Prior to that, a few treatments and interventions were found to improve survival – local work on high-flow nasal oxygen was notable – while some much-hyped treatments, like hydroxychloroquine, were shown not to work.

The South African government’s response to the pandemic has been mixed.

The early lockdown was the right move, and getting together a solid scientific advisory group showed good intent. But some lockdown regulations rightly came under wide criticism, and transparency has been patchy at best. The National Health Laboratory Service’s failure to meet demand for tests at the peak of the pandemic was disappointing, particularly following earlier assurances that it had sufficient capacity.

Worst of all, however, was the human toll the pandemic took on people, and especially on healthcare workers across the country, particularly in the Eastern Cape where the pandemic encountered a healthcare system that has already been on the ropes for years.

In South Africa, the confirmed Covid-19 death count was edging toward 25,000 by mid-December, but the real number may well end up being over 50,000. By comparison, HIV and TB death counts for 2019 are estimated at 74,000 and 58,000 respectively (although there is significant overlap with people having both HIV and TB). 

Either way, suggestions from some quarters that only a few thousand would die in South Africa and that Covid-19 would be “just another flu” turned out to be wrong. 

Meanwhile, Covid-19 and the related lockdown has hit almost all aspects of our public healthcare system hard. Fewer people tested for TB this year. Fewer medical circumcisions were conducted. In February, an ambitious plan to make HIV prevention pills available through all healthcare facilities was launched, just for Covid-19 to pour cold water over these ambitions a month later. Some HIV and TB catch-up plans are under way, but much more will be needed in 2021.

Figures released in November showed that South Africa will meet targets set for 2020 by UNAIDS regarding HIV testing and viral suppression, but that the country will miss its treatment coverage target with only seven out of ten people diagnosed with HIV receiving treatment. In October, new figures of the World Health Organisation suggested that around 20% more people fell ill with TB in South Africa than previously thought –a National TB Prevalence Survey believed to confirm these numbers has not been made public, despite being ready back in February. Either way, the numbers we have point to worrying gaps in both our HIV and TB responses.

Maybe the biggest HIV news of the year came in November when an HIV prevention injection given every two months was shown to be highly effective at preventing HIV infection in young women. As with Covid-19 vaccines, HIV prevention pills, and a new tuberculosis prevention regimen, however, the scientific breakthrough is of course only the first step. Making the new product widely available to the people who need it is another matter entirely.

If you asked us at the beginning of the year what 2020’s top health focus would be, we would have said National Health Insurance (NHI). Largely due to Covid-19, the NHI Bill is still stuck in Parliament and will likely remain there until well into 2021, if not longer. Even more solidly stuck in the mud this year have been reforms to private health sector regulation proposed in the Competition Commission’s Health Market Inquiry.

In some respects, the pandemic may have provided the ideal opportunity to experiment with some private sector contracting of the kind we are bound to see under NHI. And, while there has been some contracting (for tests, for example), whatever good may have come out of it has been overshadowed by the sheer scale of Covid-19-related corruption that we have seen in 2020. There are some glimmers of hope in that the Special Investigating Unit is looking into health sector corruption, but only time will tell whether convictions will follow.

In health governance more broadly, things remain bleak, a situation compounded by painful budget cuts just when we can least afford it. Many provincial health departments remain dysfunctional. In some departments, incompetent, but politically connected people remain in place, while more principled and competent people remain suspended or unwilling to return to an often toxic and mediocre public service. In pockets of excellence healthcare workers have done amazing work in response to the pandemic, but often they succeeded despite of, rather than because of departmental support. 

A new national resource for health strategy obtained by Spotlight earlier in the year projected that healthcare worker shortages will get worse in the coming years, should the government fail to increase investment dramatically. Whether there is capacity and political will to implement the strategy remains an open question.

Ultimately, in many provincial health departments, and maybe even the national department, the dream of a new dawn and a capable state often still plays second fiddle to patronage and cadre deployment. As it was a decade ago, this rejection of professionalism in favour of political and personal expediency remains the sand in the gears of our public healthcare system.

Covid-19 may have turned the world upside-down in 2020, but some things, alas, have not changed. DM/MC