Narrative of collapsing health care ignores real capacity gains

Speak to almost any South African about public health care and the verdict is likely to be harsh.

Long queues, overcrowded facilities, overworked staff and uneven service delivery have left many citizens convinced that the health system is steadily deteriorating.

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The frustrations are real. But the evidence tells a more complicated story.

One of the more surprising findings to emerge from the Inclusive Society Institute’s recent report, Health in South Africa, is that key measures of health care capacity have actually improved over time.

The number of people served by each public-sector doctor fell from 4 143 in 2002 to 2 795 in 2023. The number of people per nurse improved from 496 to 446 over the same period.

Pharmaceutical capacity improved even more dramatically, with the number of people served by each public-sector pharmacist falling from 40 263 in 2000 to 10 436 in 2023.

And emergency medical services have also expanded, with the number of ambulance service providers increasing from 713 in 2019 to 834 in 2024.

So at first glance, these findings appear difficult to reconcile with the experiences of many patients, because if there are more health care professionals relative to the population than before, why does the system continue to feel overwhelmed?

Part of the answer lies in the sheer scale of South Africa’s population growth. Since 1994, the country’s population has increased by more than 50%.

Every clinic, hospital, ambulance service and health care worker today serves a far larger population than was the case at the dawn of democracy.

This context matters.

Had health care capacity merely kept pace with population growth, one would expect the doctor, nurse and pharmacist ratios to remain broadly unchanged.

Instead, they improved. The implication is that capacity expanded faster than population growth in several important areas of the system.

That is not the story of a health system standing still. Nor is it a story of success.

Donating blood at the Netcare Olivedale Hospital. Pictures: Michel Bega

One of the mistakes often made in public debate is to assume that progress automatically means adequacy. It does not. A country can improve significantly and still fall short of where it needs to be. South Africa remains a case in point.

While the availability of health care professionals has improved, the country continues to face significant capacity constraints, such as public-sector doctors that remain under immense pressure, and nursing shortages and uneven distribution persist.

Moreover, many communities continue to struggle with inadequate access to health care services. Compared with many upper-middle-income countries, South Africa still has a long way to go before it can claim to have resolved its health care workforce challenges.

This helps explain why public perceptions and official statistics often seem to tell different stories. Patients do not experience health care through national averages. They experience it through the quality of care they receive when they visit a clinic or hospital.

A health care system can employ more doctors than it did 20 years ago and still leave patients waiting for hours. It can improve nurse availability while continuing to struggle with management failures, staff shortages in particular locations and uneven service standards.

The report’s findings point to exactly this reality. Capacity constraints have eased over time across multiple dimensions of the health system, but they have not disappeared.

Progress has been real, but the gap between what exists and what citizens reasonably expect remains substantial.

That distinction is important because it changes the policy conversation.

If the health system were genuinely collapsing, the priority would simply be to stop the decline. But if the system has in fact expanded while remaining under strain, then the challenge is more sophisticated.

Policymakers must continue growing capacity while simultaneously improving management, efficiency, distribution and the patient experience.

South Africans have every right to demand better health care. They should continue to do so. But those demands should be grounded in an honest assessment of where the country stands today.

The evidence does not support the narrative of a health system that has been hollowed out over time.

It points instead to a system that has expanded important elements of its capacity under difficult conditions, while still falling well short of what citizens should expect from a country at SA’s level of development.

In short, the challenge is not that SA has failed to build a larger health system. It is that the country still needs to build a better one.

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