Coronavirus Disease 2019 (COVID-19) is a novel coronavirus caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2). This novel coronavirus first emerged as a causative agent that led to a respiratory disease outbreak in December 2019 in Wuhan, China [1]. South Africa recorded its first confirmed case of COVID-19 on the 5^th March 2020. Since then the number of confirmed cases has grown exponentially, and as of the 7^th of July 2021 South Africa has recorded 2.09 million cases. Globally, health systems have been scrutinized for their capability to manage the COVID-19 pandemic. Clinically, the COVID-19 disease is characterised by a dry cough, fever, fatigue and shortness of breath. In severe cases, patients present with severe respiratory illness such as pneumonia or acute respiratory distress syndrome (ARDS), both of which could be fatal and requires hospitalization [2]. According to a presentation made to Members of the South African Parliament by the Director-General of the National Department of Health at the early days of the pandemic, there were a total of 119 416 hospital beds available from both private and public hospitals across South Africa [3, 4]. There were also 3 318 Intensive Care Unit (ICU) beds available. However, it was projected that ICU beds could exceed 14 700 at the highest peak of the COVID-19 pandemic.

In South Africa, inequalities exist in access to health services between the public and private sectors, as well as within the public sector itself, especially between urban and rural areas [5-11]. The public health system supports around 84% of the population (those who are uninsured), while the private sector only services 16% of the population (those with medical insurance). However, the annual per capita healthcare expenditure of the private sector is almost 10 times more than that of the public sector [6]. Those who can afford medical insurance are predominantly from the White population group and those who cannot afford it are mainly Black Africans. The inequalities in access to healthcare in South Africa are inherited from the racial segregation policies of the apartheid government [12]. The COVID-19 outbreak has dramatically highlighted the necessity for a more integrated healthcare system [13]. The COVID-19 pandemic presents a significant opportunity for the National Health Insurance (NHI) to be piloted in real-time. In March 2020, the Competition Commission had published a COVID-19 block exemption for the health sector for promoting better coordination, sharing of information and standardisation of practice across the entire healthcare sector, as well as promoting agreements between the National Department of Health and the private healthcare sector [14]. Spatial accessibility of healthcare facilities is also an important factor in the fight against the COVID-19 outbreak. Spatial accessibility is often concerned with the complex relationship between the spatial separation of the population and the supply of healthcare facilities and thus has a strong underlying geographic component [15-18]. Spatial accessibility is regarded as a primary deciding factor of access to healthcare and healthcare utilization [19, 20].

In addition, people’s confidence in the capability of the health system to manage the COVID-19 pandemic is also crucial. For instance, in India, it was reported that some people escaped from hospitals or quarantine mainly due to the confidence deficit in the public health system in many parts of the country [21]. Therefore, this paper explores South Africans’ perceptions of the country’s health system capability to manage the COVID-19 pandemic. It further assesses the country’s health system capacity in various geographic areas and draws comparisons with perceptions of the health system capability to manage the COVID-19 pandemic.

Overall the study findings show that people had low confidence in the South African health system, with only two out of five people indicating they thought the health system would be able to manage the COVID-19 pandemic. In similar studies conducted in Denmark and Finland, respondents reported high rates of confidence in their health systems capability to manage COVID-19 with 86% and 78% respectively [30, 31]. Black Africans, those employed part-time or informally and informal dwellers had higher confidence in the health system capability while the White population group, self-employed and those residing in formal dwellings had lower confidence in health system capability to manage the COVID-19 pandemic. This demonstrates clear divisions based on socio-economic status, geolocation as well as some racial differences in peoples’ perceptions. The majority of the Black Africans rely on the public health system almost exclusively, therefore, this increased confidence could well be due to the fact that they would not have alternative options in terms of access to healthcare, traditional forms of treatments aside. The lower confidence shown here by White respondents could be directed at the public health system and not the private which is usually very well resourced. The majority of the White population group have access to medical insurance and, therefore private medical care.

Furthermore, the older persons (70 years and above), those who perceived themselves at high risk of contracting COVID-19 and those who thought they might end up in self-isolation or quarantine had the lowest confidence in the health system capacity to manage the COVID-19 pandemic. This is concerning since people in older age groups are among those that are classified as highly vulnerable to the COVID-19 pandemic around the world, both in terms of infections and fatalities [32].

Sex and knowledge on COVID-19 were significantly associated with the perception of the health system’s capability to manage the pandemic at the national level and in four of the nine provinces. Females were less likely to have confidence in the health system capability to manage the COVID-19 pandemic than their male counterparts. The finding that men have more confidence in the healthcare system is surprising since previous studies reported that men generally access healthcare services much less than women do [33]. It is possible that women lacking confidence in the health system’s capability could be associated with how they perceive the quality thereof. Future research needs to examine people’s perceptions of health system capability in conjunction with the quality of care received. Age and self-isolation or quarantine possibility were key factors at the national level and in three provinces, while employment and risk perception were significant predictors at the national level and in two provinces. The vulnerable group, elderly (60 years and older), was a key determinant of people’s confidence in the health system capability to manage the COVID-19 pandemic at the national level and in the Western Cape. People’s risk perceptions (which are influenced by age and degree of perceived vulnerability) and knowledge about a public health problem often result in lower confidence in managing the problem.

Spatial accessibility has been previously reported to represent an important barrier to accessing healthcare services [17]. Spatial access to COVID-19 hospitals in our findings raises some concerns regarding the readiness to manage the COVID-19 pandemic, especially considering that most patients might have to be transported by road. These could be addressed by at least adding extra temporary hospitals earmarked for COVID-19 in each province that has only one COVID-19 hospital. Provinces have already started setting up additional healthcare facilities in preparation for the expected surge in the number of cases and the potential need for hospitalisation across the country. Predominantly rural provinces such as the Eastern Cape and KwaZulu-Natal should also undertake special context-specific planning for the provision which addresses challenges such as long distances between villages and available hospitals as well as poor road infrastructure. These extra hospitals should be allocated based on the geographic location and population distribution as well as the emerging trends of the pandemic whereby the number of cases and epicentres have been shifting since the outbreak of the COVID-19 pandemic. The Western Cape initially only had one hospital earmarked for COVID-19 in the early stages of the epidemic when our study was conducted. This later changed dramatically, with the province now being regarded as one of the epicentres for the pandemic with a high number of confirmed cases and number of deaths. This had to be revisited and more hospitals were allocated, as well as temporary hospitals being setup at the Cape Town International Convention Centre in the fight against the COVID-19 pandemic. Other provinces with big urban metros such as the Eastern Cape, Gauteng, and KwaZulu-Natal had to also readjust their plans as they all initially had three hospitals each that were earmarked for the response.

Our study findings show that the number of hospitals per population and the number of hospital beds per population across the country are generally lower compared to some international statistics from both public and private hospitals in Canada, Italy and Japan [34]. The current national average of 5.6 ICU beds per 100 000 in South Africa is slightly lower compared to those of some European countries such as the United Kingdom (6.6), France (9.7) and Italy (12.5). Turkey and Germany had the highest reported numbers with 46 and 29.2 ICU beds per 100 000 population [32].

Findings from this paper show that there were some similarities between people’s perceptions of health system capability and the actual health system capacity to manage the COVID-19 pandemic in some provinces. For instance, Free State was predominantly at the upper band in terms of the proportion of people who had confidence in the health systems capability and the actual health system capacity to manage the pandemic. Eastern Cape, on the other hand was at the lower end with regard to people’s confidence in health systems capability and health system capacity. Eastern Cape appeared at the upper bound only on the number of hospitals per 100 000 population and the number of hospital beds per 10 000 population. Surprisingly, Western Cape had the lowest score of people’s confidence in the health system capability to manage the COVID-19 pandemic, yet it was among the top for almost all density indicators of health system capacity except for the density on number of ICU beds per 10 000 elderly people where it was in the middle range. Western Cape also had the highest significant proportion of elderly people based on the online survey results. In addition, results showed that the elderly (60 years and above) was a significant predictor of people’s confidence in health system capability. This might have attributed to the lowest confidence in the health system capability in this province. Although North West and Limpopo had the highest proportions of people who felt that the health system was capable to deal with the COVID-19 pandemic, they were among the lowest in all health system capacity indicators.

The COVID-19 pandemic demonstrated and highlighted the urgency and the importance of the implementation of the NHI, especially in addressing the inequity of access to healthcare that exists between private and public health care. The COVID-19 pandemic has laid bare the health disparities that exists between different communities in the country due to historical structural systems brought about by both colonialism and the apartheid race based spatial planning and service provision. This pandemic provides the first and best opportunity for South Africa to reengineer the country’s health system to be united and integrated as much as possible between the public and private health systems. The COVID-19 block exemption for the health sector is an important step towards the testing the implementation of NHI. The government and all role players in the country should embrace this opportunity by ensuring that all systems that are necessary for the implementation of the NHI are put in place and expanded upon.

This study does have some limitations. One of the main limitations was that there was no clarity in the online questionnaire on whether the definition of the South African health system included both private and public sector. The survey relied on self-report which is prone to social desirability bias, which could have led to underestimation or overestimation of the people’s confidence in health systems capability to deal with the COVID-19 pandemic depending on how they understood and experience the health system. Respondents may also have been responding on their perceptions of the health system regardless of whether they utilise those services or not. Other than the above mentioned limitations, findings from this study contributes to the body of evidence on people’s perceptions about the South African health system capability and the state of health system capacity to manage the COVID-19 pandemic across the country.

To the best of our knowledge, this paper was the first to investigate people’s perception of the South African health system capability and the actual health system capacity to respond to the COVID-19 pandemic and its subsequent spread. Overall, most people had low confidence in the health system capability in managing the COVID-19 pandemic and that may be due to having the wrong perceptions or may be due to prior poor experiences in their interaction with healthcare facilities and/or services. Sex and knowledge on COVID-19 were significantly associated with the perception of the health system’s capability to manage the pandemic at the national level and in four of the nine provinces. Females were less likely to have confidence in the health system capability to manage the COVID-19 outbreak pandemic as compared to their male counterparts. Overall, the findings of this study clearly highlights the challenges of the country’s health system, both perceived or real that needed to be addressed as part of the preparation for the COVID-19 pandemic. Urgent policy interventions and implementations are recommended for continued increase in the number of ICU beds across the country with particular focus in Western Cape, Eastern Cape, KwaZulu-Natal and Gauteng. Timeous implementation of a countrywide NHI system is now more critical than ever in improving healthcare outcomes of the South African population even beyond the existence of the COVID-19 pandemic. Future research need to examine people’s perception of health system capability in conjunction with the quality of care received. Future research should also explore the country’s readiness for NHI implementation as well as preparedness for future waves of COVID-19 and other pandemics. People’s perception of NHI should also be explored, especially during and after the COVID-19 pandemic.

SPR conceived the study and TM conceptualised the paper. TM and RS conducted the analysis and interpreted the results. TM drafted the manuscript. TM, RS, SS, GWS, SD, TMa, IN, WP, ND, SJ, SP, KZ, MMo, MM, SPR contributed to interpreting the results and editing the manuscript. All authors read and approved the final manuscript before submission.