South African lives are being lost – and thousands more put at risk – as the dire shortage of ambulances and paramedics continues to hobble Emergency Medical Services (EMS), which is now short of 2 221 ambulances, reports Daily Maverick.
A horrific car crash, a major shootout, even a gas tanker explosion, are just some of the emergencies to which South Africa’s EMS members respond – often without enough ambulances or workers, adding additional pressure to the public health system, and a very real human cost to the public when an ambulance doesn’t respond timeously or is unable to respond.
The National Department of Health says there is a deficit of 2 221 ambulances, and a significant skills gap in the ranks of its paramedics.
“EMS is not a luxury, it’s a lifeline,” said Carla Griffith, a senior associate and medical legal specialist at DSC Attorneys.
She outlined a current case against the state regarding a three-year-old girl, who is unable to walk, sit up or speak, due to a three-hour delay in the arrival of the ambulance at the time of her birth.
“The baby suffered oxygen deprivation, resulting in hypoxic-ischaemic encephalopathy, and a diagnosis of moderate to severe cerebral palsy,” Griffith said.
Ambulances by the numbers
The measurement of whether there are enough ambulances to cater to a population is typically expressed by a ratio of the number of ambulances per 10 000 people.
While there is no universal international standard, NDoH spokesperson Foster Mohale said the ratio currently being used as a guide nationally and in all provinces is one ambulance per 10 000 people.
While this is the objective, a simple count can be misleading. For example, in the largely rural Northern Cape, “a ratio of 1:6 500 may be more realistic”, Mohale said, adding that population size, service demands and distance to care facilities all play a role.
Given South Africa’s current population of around 62m, according to the DOH’s own numbers, the country requires 6 228 ambulances in the public health system. There are currently 4 007. That’s a gap of 2 221, or almost 37%.
The effect of the shortages differs between rural and urban areas, South African Emergency Personnel’s Union (SAEPU) President Mpho Mpogeng told Daily Maverick.
“In maternity cases, for instance, in an urban area where you call an ambulance and it’s not responding, you’ll just take the patient in (yourself), but in rural areas you can’t do that.”
Mohale said: “Ambulances are currently procured to either replace ageing fleet, accident-damaged vehicles or when budget allocations allow, to add to the fleet establishment.”
But with provincial health budgets cut in recent years, alongside province-specific challenges and management issues, few ambulances have been purchased to address the shortfall.
“To have a functional EMS … you need National (Department of Health), provincial and local and departmental functions working together,” said Khuselwa Dyantyi, a health attorney at SECTION27.
SAEPU’s Mpogeng highlighted another challenge: many of South Africa’s EMS ambulances aren’t on the road. Parts and repair delays, high mileages and workshop backlogs can leave ambulances immobile for weeks.
“If there is a shortage, response time to an emergency is going to be very poor,” said Mpogeng.
By the numbers – paramedics
Further complicating the matter is another crucial shortage — of paramedics. Unlike ambulances, the government has no stated paramedic-to-population ratio target. According to Department of Health numbers, there are 16 445 EMS staff in employed by the state nationwide, a ratio of one EMS member to 3 887 members of the public.
Dyantyi said this was not enough “What is the point of buying ambulances when you don’t have staff to actually … drive and work in the ambulance?”
Mpogeng agreed that SA had a paramedic shortage.
Paramedics have differing skillsets and procedures they’re able to perform, grouped into Basic Life Support (BLS), Intermediate Life Support (ILS), Advanced Life Support (ALS) and Emergency Care Practitioners (ECPs).
BLS crews stabilise and transport; ILS extends the medication and intervention range; ALS is the critical-care edge of the system, and ECPs are similar to ALS teams, but allowed to perform more procedures.
Those employed by the government are heavily skewed toward BLS paramedics, who comprise almost 80%. ECP paramedics, the highest grading – the only pre-hospital paramedics who can perform certain functions such as intubation – make up a paltry 3%.
Addressing the skills gap is almost as crucial as addressing the numbers, said Dyantyi, who noted that many paramedics who receive further training end up in the private sector.
“They would be taken for training, and then they won’t come back. There is no space for them because of funding.”
TK Matshingwane, a senior paramedic and ECP practitioner, told Daily Maverick he pursued this career because, “At home, when you call an ambulance it will take two hours to get there because it’s government.”
He started out working in the public sector but, like so many of his colleagues, switched to the private sector.
The bottlenecks
The NDoH said EMS accounts for about 4% of the overall combined provincial health budgets, with strong variations between provinces: the Northern Cape and Free State are at the peak, spending 7% of their health budgets on EMS, while North West spends the lowest, 3.1%.
This spending is sometimes heavily tilted toward overtime compensation, fleet operations and infrastructure, and not necessarily on the procurement of ambulances and facilitation of paramedics into the field.
There is also a blockage in the training pipeline. In the past, completing a short course enabled one to become BLS-qualified and enter the paramedic workforce, but this is no longer the case, and higher education programmes are now required.
This might have improved quality, but throughput has slowed accordingly, meaning there are fewer qualified paramedics.
These challenges, coupled with others like the lack of centralisation of emergency services call centres, contribute to one crucial metric: the length of time it takes for medics to arrive.
Under the National Health EMS Regulations of 2017 and the Standards for Emergency Medical Services (2021), services must define and monitor their response times.
In practice, provinces aim for under 15 minutes in urban areas and under 40 minutes in rural areas, typically measured against 90% of cases rather than an average, to protect against abnormalities. The clock usually starts at the call-answer or dispatch phase, and stops when the ambulance arrives at the scene.
According to Health Department data, “For the period 1 March 2024 to 28 February 2025, the average emergency response time for Priority 1 [the highest level of emergency] calls within 30 minutes in urban settings was 48.5%, and 58.2% within 60 minutes in rural settings.”
By the department’s own metrics, it’s missing the targets by a wide margin. Not only does this mean worse outcomes for patients, it can also lead to potentially life-threatening circumstances for the ambulance crews who arrive late, often due to factors out of their control.
“When the crews do arrive, people start fighting them because of the delay,” said Mpogeng.
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