Breaking barriers to health equity for sexual and gender minorities in South Africa: A systematic review of health services and governance interventions

Abstract

Sexual and gender minorities (SGMs) in South Africa experience substantial health inequities despite a progressive constitutional framework. Stigma in healthcare settings, gaps in provider competence, and weak implementation of rights-based policies undermine progress toward sustainable development goals (SDGs) 3 (Good Health and Well-being) and 10 (Reduced Inequalities). This systematic review synthesized evidence on health system barriers, interventions, and governance approaches affecting SGM health and health equity for SGMs. Searches of bibliographic databases and grey literature (January 2000–December 2024) retrieved 978 records; 15 studies met the inclusion criteria. Findings were synthesized narratively using the social determinants of health framework, the availability-accessibility-acceptability-quality framework, and rights-based and participatory governance perspectives. Meta-analysis was not feasible due to heterogeneity in designs, populations, interventions, and outcomes. Across qualitative, mixed-methods, cross-sectional, and policy analyses, SGMs reported discrimination, moralizing attitudes, breaches of confidentiality, and consequent care avoidance, especially in rural and under-resourced settings. Structural barriers included the absence of sexual orientation and gender identity indicators in routine information systems, fragmented implementation of protective policies, and limited mechanisms for accountability and redress. Interventions clustered around healthcare worker training and sensitization; community- and peer-led psychosocial and HIV-prevention programs; and rights-based policy and participatory governance initiatives. Multi-level approaches integrating these domains appeared most promising for improving acceptability, trust, and uptake but were small-scale, unevenly evaluated, and rarely assessed long-term. Legal protections are necessary but insufficient; system-wide reforms in training, data systems, accountability, and meaningful SGM participation in health governance are required to translate constitutional commitments into inclusive, high-quality care and advance SDGs 3 and 10.