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. 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.

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

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. A country can improve significantly and still fall short of where it needs to be.