South Africa’s health system is struggling, not collapsing

Few issues evoke stronger emotions than healthcare. Unlike economic growth, foreign policy or constitutional reform, healthcare is intensely personal.

Most South Africans have either sat for hours in a clinic waiting room, struggled to access treatment for a family member, or experienced first-hand the frustrations that accompany an overstretched public health system.

Hence, it is hardly surprising that many have concluded the system is in a state of collapse. The evidence, however, suggests something very different.

This is not an argument that South Africa’s health system is performing well. Far from it. Service delivery in many facilities remains unacceptably poor. Long waiting times, overcrowding, staff shortages and administrative failures are genuine issues that affect millions of South Africans every day.

Nor should anyone minimise the frustration and indignity which often accompany those experiences. But there is a difference between a health system that is struggling and one that is collapsing.

The question is not whether patients are frustrated. Clearly, many are. The question is whether health outcomes themselves are deteriorating.

On this measure, the evidence points overwhelmingly otherwise. Consider what has happened to child mortality in the past two decades.

In 2002, some 57 infants died for every 1 000 live births in SA. By 2024 this figure had dropped to below 23.

The under-five mortality rate followed a remarkably similar trajectory, declining from close to 80 deaths per 1 000 live births to fewer than 30 over the same period. Behind the statistics lie hundreds of thousands of children who survived infancy and early childhood and who might not have done so a generation ago.

The same pattern emerges with life expectancy. At the height of the HIV/Aids crisis, South Africans were dying younger and in greater numbers than at any point in the democratic era.

In 2002, life expectancy stood at less than 55 years. Today it exceeds 66. Put differently, the average South African can expect to live more than a decade longer than was the case just over 20 years ago.

Few indicators provide a more comprehensive assessment of a nation’s health than how long its citizens live. On this measure, South Africa has made substantial progress.

Part of the explanation lies in the country’s response to some of its most serious public health challenges, such as new HIV infections, which have fallen from more than 380 000 cases a year at their peak in the late 2000s to about 142 000 in 2024, a reduction of more than 60%.

Tuberculosis prevalence increased from approximately 475 cases per 100 000 in 1990 to a peak of around 857 per 100 000 before subsequently declining.

These developments seldom feature prominently in public debate, but they rank among the most significant public health gains of the democratic era.

It is difficult to reconcile such improvements, together with substantial reductions in child mortality and a gain of more than a decade in life expectancy, with the notion of a health system in freefall. At this point, critics will understandably object that these statistics bear little resemblance to their lived experience.

They will point to overcrowded hospitals, medicine shortages and facilities which often appear unable to cope. They will say, with some justification, patients do not experience healthcare through national averages and long-term trends, but through the quality of service they receive.

This is correct. But it does not invalidate the evidence. Rather, it highlights an important distinction.

Service quality and health outcomes are related, but they are not the same thing. A patient may endure an unacceptable wait at a clinic and still benefit from a health system that is more effective at preventing child mortality than it was 20 years ago.

A hospital may suffer from management failures while contributing to longer life expectancy and improved disease outcomes. These realities are not mutually exclusive.

This is perhaps the central paradox of SA healthcare. The system is getting better outcomes than many realise, while delivering a level of service that often falls short of reasonable expectations.

The mistake made by government apologists is to focus exclusively on the positive indicators and ignore the daily frustrations experienced by patients.

The mistake by pessimists is to focus exclusively on those frustrations and ignore the measurable improvements that have taken place over time. Neither approach serves the public interest.

Good policy begins with an accurate diagnosis. If we convince ourselves everything is collapsing, we risk overlooking interventions that have demonstrably worked and abandoning approaches that have saved lives.

If, on the other hand, we become complacent because some indicators are moving in the right direction, we risk entrenching a level of service delivery that remains unacceptable.

The evidence suggests a more nuanced conclusion. SA’s health system is under considerable strain. It is often inefficient.

It frustrates the people who depend on it, but is not collapsing. A collapsing system does not typically produce longer lives, fewer child deaths and sustained improvements in the management of major diseases.

South Africans have every right to demand better healthcare. They should continue to do so. But that demand should be rooted in an honest assessment of where we stand today.

The evidence does not support the narrative of a health system in collapse. It points to a system that has delivered meaningful improvements under difficult conditions, while continuing to fail many patients in their day-to-day experience of care.

The task ahead is not to rescue a collapsed system. It is to fix a functioning one that is still falling well short of its potential.

This article forms part of the institute’s True SA evidence series, which examines public policy debates through empirical data and long-term trends