Hunger, Illness and the Limits of Cash: Lessons From South Africa

South Africa's pandemic response exposed a difficult policy tension: expanding financial assistance did not coincide with a sustained improvement in reported health. In "COVID-19, Vulnerability, and Health in South Africa: Evidence on the Changing Role of Social Cash Transfers," published in Economies, Mashekwa Maboshe of the University of Zambia and Ingrid Woolard of the University of Sussex Business School examine how household vulnerability and social grants were associated with health as COVID-19 unfolded.

The key finding is more nuanced than a verdict on whether cash transfers worked. People living in grant-receiving households were less likely to report poor health early in the pandemic, after accounting for observed differences. By April–May 2021, the association was no longer statistically significant. Meanwhile, household hunger and chronic illness were more strongly associated with poor health, suggesting that prolonged emergencies require financial assistance and functioning essential services to operate together.

Health Deterioration Outlasted the Initial Shock

The researchers link South Africa's National Income Dynamics Study with its coronavirus telephone follow-up, using a 2017 baseline and pandemic surveys conducted in May–June 2020, February–March 2021 and April–May 2021. Earlier survey rounds provide a longer pre-pandemic comparison. Their health measure combines respondents who described their health as "fair" or "poor," capturing an overall assessment of wellbeing rather than a particular diagnosis or confirmed COVID-19 infection.

Across the authors' comparisons, poor self-reported health more than doubled relative to its pre-pandemic average and remained elevated through the final survey. The persistence is significant: the burden people experienced extended beyond the immediate disruption of the first lockdown. However, the measure cannot disentangle infection, psychological strain, nutritional deprivation and interrupted treatment. It indicates a broad deterioration in perceived health while leaving the contribution of each pathway unresolved.

The study also identifies unequal exposure to deterioration. Between the first and final pandemic surveys, approximately 32% of initially healthy respondents in the poorest income fifth moved into poor health, compared with about 21% in the wealthiest fifth. These descriptive differences suggest that households entered the emergency with unequal capacity to withstand it. They do not establish which resources or disadvantages drove the gap, but they challenge evaluations that treat average recovery as evidence of recovery across society.

Hunger and Chronic Illness Exposed Deeper Vulnerabilities

Household hunger emerges as a particularly strong correlate of poor health. In the fully adjusted models, living in a household where someone experienced hunger was associated with a 9.2-percentage-point higher probability of poor health in May–June 2020. By April–May 2021, the estimated difference had reached 16.6 percentage points. The larger later association suggests that persistent material deprivation deserves attention even when headline measures of economic disruption begin to improve.

Chronic illness followed a similar pattern, with the estimated association increasing from 3.2 to 9.3 percentage points, although the early estimate had weaker statistical support. The authors interpret this pattern as consistent with difficulties maintaining routine care and obtaining medication. Such mechanisms are plausible, but the models do not directly demonstrate them. The policy concern is nevertheless clear: people dependent on continuous treatment may face needs that an income payment alone cannot satisfy.

Income loss presents a more qualified result. It was associated with a 3.1-percentage-point higher probability of poor health early in the pandemic, but its later estimate was statistically insignificant in the fully adjusted model. Reporting lost earnings and experiencing hunger are related but distinct indicators. For programme design, the findings suggest a reason to monitor households' ability to meet basic needs alongside income changes, while avoiding the assumption that any single indicator captures the full burden of vulnerability.

The Early Grant Advantage Was No Longer Detectable

South Africa expanded assistance through temporary increases to existing grants and the introduction of the R350 monthly Social Relief of Distress grant for eligible unemployed adults in May 2020. Against that backdrop, the study estimates that household grant receipt was associated with a 3.9-percentage-point lower probability of poor health during the first pandemic survey. Additional checks incorporating pre-pandemic health, income position and grant receipt preserved the broad early pattern.

By the final survey, the estimated difference had narrowed to 0.4 percentage points and was statistically insignificant. Further analysis associated the initial advantage primarily with Child Support Grant households, indicating that the aggregate result was not uniform across programmes. The authors also found only limited evidence that grants moderated particular vulnerabilities, chiefly an early association involving household income loss. The evidence therefore supports a cautious account of early protection rather than a claim of comprehensive health insurance through transfers.

The later result should not be read as proof that grants ceased to help. This is an observational study, and unmeasured differences between recipients and non-recipients may influence the estimates. Moreover, a significant association in one period and an insignificant association in another does not itself establish a statistically significant change between them. The authors' explanation, that cumulative hardship and service disruptions may have weakened the apparent health benefit, remains an interpretation requiring further investigation.

Build Protection Around What Households Can Actually Access

The strongest policy implication is to connect emergency income support with reliable access to food and healthcare. The authors recommend nutrition interventions, continuity of primary care and uninterrupted chronic medication access alongside cash transfers. Their study does not test a combined programme, so it cannot specify the best package or spending balance. It does, however, identify a practical weakness in judging emergency assistance mainly by how many people receive payments.

For governments and development agencies, evaluation should follow whether recipients can obtain adequate food, maintain treatment and avoid worsening deprivation over time. Civil society organizations could help identify unmet needs among households already receiving support. Businesses involved in food distribution, medicine delivery and payment services could contribute to implementation, although commercial opportunities and health benefits would need independent assessment. Greater coordination should also avoid creating administrative requirements that make essential assistance harder to access.

Several limitations shape how far the findings can travel. Telephone surveys may miss people with unreliable communications access, and excluding incomplete records reduced the fully adjusted samples to 4,131 and 3,398 observations. The baseline predates COVID-19 by several years, while unequal survey intervals complicate comparisons of health transitions. South Africa's extensive grant infrastructure also means countries with narrower coverage should examine their own delivery conditions before adopting the same policy conclusions.

For Global South stakeholders, the broader relevance lies in the relationship between poverty reduction, nutrition and health, the linked ambitions of SDGs 1, 2 and 3. Further research should test combined support packages and examine payment size, regularity, service availability and clinical outcomes. South Africa's experience raises a demanding standard for crisis protection: financial assistance must be evaluated alongside the conditions that allow households to turn it into sustained wellbeing.