Few issues evoke stronger emotions than healthcare. Unlike economic growth, foreign policy or constitutional reform, healthcare is intensely personal, writes Daryl Swanepoel in IOL, suggesting that, particularly when it concerns South Africa, there is a difference between a health system that is struggling and one that is collapsing.
Swanepoel writes:
Most South Africans have either sat for hours in a clinic waiting room, struggled to access treatment for someone, or experienced first-hand the frustrations that accompany an overstretched public health system. It is therefore hardly surprising that many have concluded that the system is in a state of collapse.
While the conclusion is understandable, the evidence, however, suggests something rather different.
This is not an argument that our 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 problems that affect millions of people every day.
Nor should anyone minimise the frustration and indignity that often accompany those experiences.
But there is a difference between a health system that is struggling and one that is collapsing. The question is therefore not whether patients are frustrated. Clearly many are. The question is whether health outcomes themselves are deteriorating.
On this measure, the evidence points overwhelmingly in the opposite direction.
Consider what has happened to child mortality over the past two decades. In 2002, 57 infants died for every 1 000 live births in South Africa. By 2024, that figure had fallen 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 below 30 over the same period.
Behind those 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 when one examines 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 more than 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, like new HIV infections which have fallen from more than 380 000 cases per year at their peak in the late 2000s to around 142 000 in 2024, a reduction of more than 60%.
TB prevalence, meanwhile, increased from 475 cases per 100 000 population 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, 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 that often appear unable to cope with demand.
They will argue, with some justification, that patients do not experience healthcare through national averages and long-term trends. They experience it through the quality of service they receive when they need care.
That observation is entirely 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 nevertheless contributing to longer life expectancy and improved disease outcomes. These realities are not mutually exclusive.
This is perhaps the central paradox of South African healthcare. The system is producing better outcomes than many people realise, while simultaneously 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 made by the 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 that 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. South Africa’s health system is under considerable strain. It is often inefficient. It frequently frustrates the people who depend on it.
But it is not collapsing. A collapsing health 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 the country stands today.
The evidence does not support the narrative of a health system in collapse. It points instead to a system that has delivered meaningful improvements in health outcomes under difficult conditions, while continuing to fail too 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.
Daryl Swanepoel is Chief Executive Officer of the Inclusive Society Institute
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