Water-Energy-Food Security and Health in South Africa

Importance: Water, energy, and food (WEF) insecurities are widespread in South Africa and are associated with adverse health outcomes. However, research has typically examined these insecurities separately, resulting in limited understanding of their interconnected associations with health and the pathways through which they may influence health outcomes. Objective: To develop a conceptual framework describing the associations between WEF insecurities and health outcomes in South Africa by synthesizing existing evidence on the pathways through which WEF insecurities may influence health. Evidence Review: This scoping review used an iterative process combining literature synthesis and expert consultation. A scoping review of peer-reviewed studies was conducted to identify evidence of WEF-health associations and inform a preliminary framework. This was subsequently refined through expert consultation, including 13 semistructured interviews with academic and practitioner experts (October-November 2024) and 2 in-person workshops (March 2025). Literature searches were performed between September 2024 and April 2025 using Web of Science, PubMed, and Scopus. Reference lists of retrieved articles were screened to identify additional studies. Study selection followed predefined inclusion criteria based on the population-concept-context framework: human populations in South Africa (population), associations between WEF insecurities and health outcomes (concept), and publication between 2005 and 2025 (context). Methods and results are reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews guidelines. Findings: A total of 137 articles were included in the review, and 26 experts were consulted. Evidence indicated that WEF insecurities were associated with a range of adverse health outcomes, including communicable diseases, noncommunicable diseases, and injuries. Key pathways included inadequate water, sanitation, and hygiene; poor nutrition; and reliance on traditional energy sources. Additional identified intermediating factors included increased exposure to vector-borne diseases associated with surface water, overcrowded living conditions, and intimate partner violence. While most studies examined WEF-related exposures in isolation, limiting understanding of their combined and interacting effects, this synthesis revealed interconnected pathways that may link WEF insecurity and health. Conclusions and Relevance: The findings of this scoping review of 137 articles plus expert consultation suggest that WEF insecurities are interconnected with determinants of health in South Africa, operating through multiple pathways. The conceptual framework clarifies how intersecting WEF insecurities may jointly influence health outcomes and highlights the need for integrated research and policy approaches addressing the WEF-health nexus. Applying such integrated perspectives may support more effective strategies to reduce health risks in settings facing overlapping resource insecurities.