TRUE SOUTH AFRICA - Evidence Series: Health in South Africa
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DISCLAIMER
Views expressed in this report do not necessarily represent the views of
the Inclusive Society Institute or its Board or Council members.
This report was prepared with the assistance of AI technology, including ChatGPT.
JUNE 2026
Author: Inclusive Society Institute
CONTENTS
Executive summary
Introduction
Methodological note and data sources
PART I: Qualitative improvements in health outcomes
PART II: Health system capacity
PART III: System efficiency and performance
Conclusion
References
Annexure A
Cover photo: Microsoft Copilot (2026) Education in South Africa. AI generated image
LIST OF FIGURES
Figure 1: Vaccination coverage of children in South Africa, 2017/18–2022/23
Figure 2: Infant mortality rate deaths of children under I yr in South Africa, 2002–2024
Figure 3: Under-five mortality rate in South Africa, 2002–2024 (per 1 000 live births).
Figure 4: Life expectancy at birth in South Africa, 2002–2024 (years)
Figure 5: Severe acute malnutrition case fatality rate in South Africa, 2017/18–2022/23
Figure 6: HIV prevalence among adults aged 15–49 in South Africa, 2002-2024
Figure 7: New HIV infections in South Africa, 2009–2024
Figure 8: Tuberculosis prevalence in South Africa, 1990-2019 (per 100,000 population)
Figure 9: Number of people per public-sector doctor in South Africa, 2000–2023
Figure 10: Number of people per nurse in South Africa, 2000–2023 (public health system)
Figure 11: Number of public-sector pharmacists in South Africa, 2000–2023
Figure 12: Number of people per public hospital bed in South Africa, 2020–2023
Figure 13: Number of ambulance service provider organisations in South Africa, 2019–2024
Figure 14: In-patient bed utilisation rate in South Africa, 2015/16–2022/23 (%)
Figure 15: Average length of stay in public hospitals in South Africa, selected years 2008–2022/23
EXECUTIVE SUMMARY
South Africa’s public health system is under pressure. But it is not collapsing.
This report looks at health outcomes, system capacity and basic efficiency using long-term data, not headlines or anecdotes. The picture that emerges is mixed, but more positive than public debate often suggests.
Health outcomes have improved. Fewer children are dying young. People are living longer. New HIV infections have fallen sharply since their peak. Tuberculosis prevalence has dropped dramatically since the early 2010s, reversing one of the country’s most serious public health crises.
These gains did not happen overnight, and they are not complete. But they are real, sustained and visible across multiple indicators. The health system has expanded. There are more health workers, more infrastructure and broader emergency coverage than in the past. Capacity remains uneven and stretched in places, but the system today is larger and better resourced than it was a decade ago.
The system is not grinding to a halt. Hospitals are using their beds actively, without showing signs of permanent overload. Patients are, on average, spending less time in hospital than before. These are modest indicators, but they matter. They suggest that the system is still functioning and adapting under pressure.
So why does it still feel broken? Because experience is local and personal. Waiting times, overcrowding and staff shortages are felt directly. Service failures are visible and frustrating. Successes, lives saved, infections prevented, are largely invisible.
Both things can be true at the same time: outcomes can improve while confidence remains low.
The evidence in this report does not justify complacency. Serious problems remain, especially in quality, access and uneven performance. But it also does not support a story of total failure. The reality is more uncomfortable and more useful.
South Africa’s health system has delivered meaningful progress under difficult conditions. The challenge now is not to deny that progress, nor to exaggerate success, but to build on what works, fix what doesn’t and close the gap between measured improvement and lived experience.
A NOTE ON CONTEXT
South Africa is widely described as a country in decline, even a country in collapse. Public debate, media commentary and everyday conversation are saturated with the language of failure: a failed state, a failed government, a society coming apart at the seams. That is the dominant public perception. This report was developed precisely to test that perception against evidence. It asks a simple question: when we look carefully at the data, when we measure performance, rather than emotion, does the story of collapse hold?
The evidence does not support that conclusion. What it shows instead is a country under real and sustained strain, economically, socially and institutionally, but not a country that has collapsed, and not a state that has failed. The challenges are serious and should not be minimised, yet they coexist with resilience, capacity and untapped potential. South Africa’s outcomes are weaker than they should be, but stronger than public perception suggests. With a firmer growth path, improved institutional performance and greater policy consistency, the trajectory can change. This report therefore argues for realism without despair: less denial of strain, but also less surrender to hopelessness. South Africa warrants more honesty and more confidence than the prevailing narrative allows.
INTRODUCTION
Public debate about South Africa’s health system is often conducted in extremes. On one side, there are assertions of systemic collapse, failure or unsustainability. On the other, official narratives emphasise policy intent, expenditure or institutional design as evidence of progress. Both approaches risk obscuring what ultimately matters most: what the evidence says about lived health outcomes, the capacity of the system to deliver care and how effectively that capacity is translated into results.
This report forms part of the True South Africa evidence series, which seeks to interrogate dominant narratives through disciplined use of empirical indicators, rather than assertion or sentiment. As with safety and crime, health outcomes evoke strong emotional responses, and justifiably so. Illness, preventable death and unequal access to care are experienced directly and personally. Yet emotion alone is an unreliable guide to diagnosis. If despair replaces analysis, it becomes difficult to distinguish between strain, uneven performance and collapse.
The purpose of this report is therefore not to defend institutions, policies or outcomes, nor to minimise hardship or suffering. Its purpose is narrower and more exacting: to examine whether the health system, as reflected in the available data, shows evidence of deterioration, improvement or mixed performance across three analytically distinct dimensions, namely qualitative health outcomes, system capacity and system efficiency and performance.
The structure of the report reflects this logic. Rather than beginning with conceptual framing or conclusions, the analysis proceeds indicator by indicator, allowing patterns to emerge from the data itself. Qualitative health outcomes are examined first to establish what has happened to survival, early-life protection, nutrition and chronic disease burden. Capacity indicators are then assessed to determine whether the system plausibly supports those outcomes. Finally, efficiency and performance indicators are considered to understand how well available resources are converted into results under conditions of constraint.
Throughout, the analysis is intentionally confined to the data in Annexure A. No external benchmarks, counterfactuals, or policy projections are introduced. This constraint is not a limitation, but a discipline. It ensures that claims are grounded, auditable and proportionate to what the evidence can support.
The report therefore does not ask whether South Africa’s health system is ideal, equitable or sufficiently resourced. It asks a more basic and prior question: what does the evidence show about how the system is functioning in practice, and how should that evidence be interpreted without exaggeration or denial?
METHODOLOGICAL NOTE AND DATA SOURCES
This report adopts an evidence-led approach to assessing recent trends in health outcomes, health system capacity and efficiency in South Africa. Wherever possible, analysis is based on a single consolidated health dataset (CRA, 2025), drawing on officially reported national indicators and presenting long-run trends rather than point-in-time snapshots.
The underlying dataset is compiled from official administrative and statistical sources, including routine reporting systems of the National Department of Health, national surveillance programmes and population-level estimates produced by Statistics South Africa. Indicators such as child mortality, HIV prevalence, vaccination coverage and malnutrition outcomes are derived from these established reporting frameworks and reflect nationally published series, rather than newly constructed estimates.
Indicators are selected to capture three distinct dimensions of system performance. First, qualitative health outcomes are assessed using mortality, survival and disease-related indicators that speak directly to population wellbeing. Second, health system capacity is examined through measures of infrastructure, personnel and service availability. Third, efficiency is explored through indicators that reflect the relationship between resources, utilisation and outcomes.
In one instance, an external data source is used. To assess population longevity, the report draws on Statistics South Africa’s Mid-year Population Estimates (Statistical Release P0302) to present trends in life expectancy at birth, which provide a direct measure of how long people live on average. This source is used, because the required indicator is not available in the primary dataset and is introduced explicitly and transparently for this purpose alone.
Throughout the report, graphs present national-level trends using consistent visual conventions, with data labels limited to key reference points to emphasise direction and magnitude of change, rather than short-term fluctuations. The intention is not to provide an exhaustive evaluation of the health system, but to establish an evidence-based baseline from which informed policy discussion can proceed.
PART I
QUALITATIVE IMPROVEMENTS IN HEALTH OUTCOMES
This part examines whether lived health outcomes in South Africa show evidence of improvement, deterioration or uneven performance over time. The focus is not on policy intent or institutional design, but on measurable outcomes that affect survival, resilience and everyday wellbeing, as reflected in the attached health data.
The indicators selected are deliberately foundational. They capture early-life protection, preventable death, nutrition and chronic disease burden, all areas where sustained improvement cannot occur without some combination of effective healthcare delivery, improved living conditions and social protection.
VACCINATION OF CHILDREN
Childhood vaccination is among the clearest indicators of basic health system functioning. It reflects not only clinical capacity, but also supply chains, outreach, record-keeping and public trust in health services. Because most childhood vaccines prevent illnesses that are otherwise highly lethal or disabling, vaccination coverage operates as a leading indicator of future child survival outcomes.
The data shows that vaccination coverage for children has been largely sustained at high levels over time, with some fluctuation across years and provinces and while coverage is not uniformly optimal and short-term disruptions are visible in certain periods, the overall picture is one of continued system operation, rather than collapse.
Importantly, vaccination coverage does not exhibit the kind of structural decline that would be expected if primary healthcare delivery had ceased to function. Even where performance weakens, it does so unevenly, rather than universally. This suggests strain and variability, not systemic withdrawal.
Vaccination outcomes therefore provide an early signal that basic preventative healthcare continues to reach a substantial proportion of children, despite broader pressures on the health system.
What this indicator can tell us:
whether primary healthcare delivery remains operational,
whether children are protected against major preventable diseases,
whether system strain has translated into service abandonment.
What it cannot tell us on its own:
the quality of follow-up care,
nutritional status,
or outcomes beyond early childhood.
Figure 1: Vaccination coverage of children in South Africa, 2017/18–2022/23
(Source: CRA, 2025)
INFANT MORTALITY RATE
The infant mortality rate measures the number of deaths of children that are under one year of age per 1 000 live births in a given year.
Infant mortality is one of the most sensitive indicators of health system effectiveness. It captures antenatal care, maternal health, birth conditions, early nutrition and postnatal support, all within the first year of life.
The data show a long-term decline in infant mortality, notwithstanding periods of slower improvement or temporary stagnation. This decline is significant, because infant mortality is resistant to cosmetic improvement: it falls only when multiple components of the health and social system function together.
The persistence of lower infant mortality rates over time suggests that:
maternal and child health interventions have had sustained impact,
early-life survival has improved relative to earlier periods,
and gains have not been fully reversed, even under system strain.
This does not imply that infant mortality is low by global standards, nor that disparities have been eliminated, but what it does indicate, however, is that foundational conditions for infant survival have strengthened, rather than deteriorated wholesale.
What this indicator can tell us:
whether early-life survival has improved,
whether basic maternal and neonatal care is functioning,
whether deterioration has reached catastrophic levels.
What it cannot tell us on its own:
outcomes beyond infancy,
the distribution of survival gains across income or geography.
Figure 2: Infant mortality rate deaths of children under I yr in South Africa, 2002–2024 (per 1,000 live births).
(Source: CRA, 2025 dataset.)
UNDER-FIVE MORTALITY RATE
The under-five mortality rate measures the number of deaths of children under the age of five per 1 000 live births in a given year.
Under-five mortality extends the infant mortality lens by capturing survival beyond the first year of life. It reflects immunisation effectiveness, nutrition, access to primary healthcare and timely treatment of common childhood illnesses.
The data shows that the under-five mortality rate has declined alongside the infant mortality rate, which reinforces the conclusion that improvements are not confined to birth outcomes alone, in that the survival gains persist into early childhood, which is particularly sensitive to food security, sanitation and primary healthcare access.
This pattern strengthens the argument that improvements are structural, rather than accidental, because if early gains were limited to neonatal care alone, under-five mortality would not follow the same trajectory.
At the same time, the rate of improvement is uneven, and levels remain unacceptably high in absolute terms and therefore the indicator supports a narrative of incomplete, but real progress, rather than either success or collapse.
Figure 3: Under-five mortality rate in South Africa, 2002–2024 (per 1 000 live births).
(Source: (CRA, 2025).)
OVERALL MORTALITY RATE
Overall mortality, in turn, provides a population-wide measure of survival, which is different to the infant or under-five mortality, in that it reflects the life-expectancy across all age groups and disease categories.
Within the data, overall mortality trends show stabilisation and significant improvement over time, particularly when read alongside declines in child mortality and improved HIV treatment outcomes. This is a significant finding, because overall mortality is influenced by a wide range of factors, including chronic disease, infectious disease, injury and general living conditions.
Crucially, improvements in overall mortality does not only suggest better clinical care, but so too, improved baseline resilience among households, particularly at lower income levels. In the South African context, the evidence plausibly reflects improved access to basic healthcare, better management of HIV and TB diseases, and an improvement in the material conditions that reduce vulnerability to premature death.
Overall mortality therefore functions as a structural signal, rather than a precise diagnostic tool, since when it improves or stabilises in tandem with child survival indicators, it supports the conclusion that lived health outcomes have strengthened in important respects.
Figure 4: Life expectancy at birth in South Africa, 2002–2024 (years)
(Source: Stats SA, 2024)
MALNUTRITION
Malnutrition sits at the intersection of health and social conditions, in that it directly affects a child’s development, their immune function and their mortality risk, whilst it also serves as a proxy for food security and household stability.
The data shows that malnutrition in South Africa remains a persistent challenge, particularly among children, but that said however, trends over time do not indicate a generalised deterioration and instead, they suggest ongoing vulnerability with periods of improvement, rather than sustained collapse.
When read alongside improvements in child survival, the malnutrition data points to a nuanced picture that suggests that the nutritional outcomes are not uniformly good, but neither have they worsened to levels that would negate gains in mortality reduction, which implies that extreme deprivation has been mitigated, even if not eliminated.
This reinforces the interpretation that the baseline living conditions for the poorest households have improved relative to earlier periods, despite inequality and food insecurity remaining as pressing concerns.
Figure 5: Severe acute malnutrition case fatality rate in South Africa, 2017/18–2022/23
(Source: CRA, 2025)
NUMBER AND PROPORTION OF PEOPLE HIV-POSITIVE
HIV remains one of the most significant determinants of population health in South Africa and the number and proportion of people living with HIV reflect both the historical infection patterns and the successes in the prevention and treatment efforts.
The data show a large, but stabilising HIV-positive population, which is a pattern that must be interpreted carefully, because high prevalence does not automatically indicate failure. In a context of effective treatment, it can also reflect improved survival among people living with HIV.
When read together with declining HIV-related mortality, expanded ART coverage and improved overall survival indicators, the HIV data support an interpretation of managed chronic disease burden, rather than uncontrolled epidemic resurgence.
Figure 6: HIV prevalence among adults aged 15–49 in South Africa, 2002-2024
(Source: CRA, 2025)
NEW HIV INFECTIONS
Trends in new HIV infections provide a critical indicator of progress in preventing transmission and reducing the future burden of disease and in South Africa, the national trajectory shows a pronounced and sustained decline in new HIV infections over the past decade and a half.
New HIV infections peaked in the late 2000s at levels exceeding 380,000 new cases per year, but from that point onwards, the trend shows a consistent downward movement, and by 2015, the number of new infections annually, had fallen to below 250,000 and by 2024 the estimated number of new infections had declined further to approximately 142,000 per year.
This represents a reduction of more than 60 per cent from peak levels in 2009-2011. While year-to-year fluctuations are evident, the overall direction of change is unambiguous and suggests a sustained long-term improvement, rather than it being temporary or cyclical effect.
Figure 7: New HIV infections in South Africa, 2009–2024
(Source: CRA, 2025)
TUBERCULOSIS PREVALENCE
Tuberculosis prevalence provides a long-run indicator of population-level disease burden and the effectiveness of prevention, detection and treatment over time. The trend for South Africa shows a clear and sustained reduction in TB prevalence over the past three decades, which followed a period of deterioration during the late 1990s and early 2000, where TB prevalence rose steadily from the mid-1990s, increasing from approximately 475 cases per 100,000 population in 1990 to a peak of around 857 per 100,000 in 2012. This period coincided with the height of the HIV epidemic, during which period the incidence of TB and its prevalence increased sharply due to immune suppression that elevated susceptibility to infection and TB reactivation.
From 2012 onwards, however, the trend reversed decisively, with TB prevalence declining markedly, falling to approximately 715 per 100,000 in 2013 and continuing its downward trend to around 301 per 100,000 by 2018; and although a modest increase was observed in 2019 (coinciding with the COVID pandemic), the prevalence levels remain less than half of their peak values recorded earlier in the decade.
This sustained reduction represents a significant improvement in population health outcomes and while the data does not allow for causal attribution, the decline in TB prevalence is consistent with expanded access to antiretroviral treatment, improved TB detection and treatment coverage and strengthened integration of HIV and TB services. Importantly, the trend reflects not a short-term fluctuation, but a structural shift away from the exceptionally high TB burden that characterised South Africa during the peak years of the HIV epidemic.
Taken together, the TB prevalence trend points to a meaningful reduction in one of South Africa’s most persistent public health challenges, which provides strong evidence of improved health outcomes that manifested over the long term.
Figure 8: Tuberculosis prevalence in South Africa, 1990-2019 (per 100,000 population)
(Source: CRA, 2025)
INITIAL OBSERVATION
Taken together, the indicators examined in Part I point to a pattern of measurable and sustained improvement in several foundational health outcomes in South Africa, but that said, it is also true that areas of continuing vulnerability and uneven progress still remain. The evidence does not support a narrative of systemic health collapse, but neither does it suggest that gains have been uniform, complete or evenly distributed.
Across early-life indicators, the data show long-run declines in infant and under-five mortality, signalling improved survival through the most vulnerable stages of life. These improvements are particularly significant, because they reflect the combined functioning of maternal care, early nutrition, immunisation and primary healthcare delivery. The persistence of these gains over time suggests structural improvement, rather than temporary or episodic success.
Indicators of population-level survival reinforce this conclusion, since trends in overall mortality and life expectancy at birth point to improved longevity, which implies that survival gains extend beyond childhood into adulthood. In the South African context, such improvements are difficult to achieve without better management of chronic disease, reduced premature mortality and improved baseline household resilience.
Outcomes related to HIV and tuberculosis, historically among the most severe sources of morbidity and mortality, show especially important shifts. New HIV infections have declined substantially since their peak in the late 2000s, reducing future disease burden and long-term treatment demand, and at the same time, TB prevalence has fallen sharply from its early-2010s peak, representing a decisive reversal of the exceptionally high burden associated with the height of the HIV epidemic. Although neither indicator implies eradication, both point to durable improvement, rather than stagnation or regression.
Nutritional indicators present a more nuanced picture in that malnutrition remains a persistent concern, particularly among children, and progress is neither uniform nor sufficient, but, that said, the absence of sustained deterioration, when read alongside improvements in child survival, it does suggest that extreme deprivation has at least been mitigated over time, even as food insecurity and inequality continue to shape health outcomes.
Taken as a whole, the evidence revealed in Part I indicates real, albeit incomplete progress; where improvements are observable across multiple outcome indicators and they seem to persist over long periods. And they align across related measures, which lends them credibility. At the same time, the data reflect strain, uneven performance and ongoing risk, particularly for vulnerable groups.
The appropriate conclusion at this stage is therefore neither complacency nor alarm. The evidence supports a measured, but clear finding: population-level health outcomes in South Africa have, on balance, improved over the period under review. The critical questions that follow are whether the health system’s capacity plausibly supports these outcomes, and how efficiently that capacity is being converted into results under sustained pressure, issues taken up in Parts II and III.
PART II
HEALTH SYSTEM CAPACITY
This part examines whether South Africa’s health system has expanded, stagnated, or thinned in its ability to deliver care. Capacity here is understood in practical terms: the availability of health professionals, hospital infrastructure and emergency reach relative to population demand.
Capacity indicators do not measure outcomes directly. Rather, they test whether the system plausibly could produce the outcomes observed in Part I. Where outcomes improve despite constrained capacity, strain is implied. Where capacity erodes, risks accumulate.
PEOPLE-TO-DOCTOR RATIO
The people-to-doctor ratio is a core indicator of clinical capacity. It reflects how thinly medical expertise is spread across the population and, by extension, the intensity of pressure placed on individual practitioners.
The data shows that South Africa continues to experience a high people-to-doctor ratio, particularly in the public sector and while the absolute number of registered doctors has increased over time, population growth and uneven distribution mean that per-capita access to doctors remains constrained.
Importantly, the data does not indicate a collapse in doctor availability, rather, they point to incremental increases in absolute numbers, and a significant improvement in the number of people-per-public sector doctor. Nevertheless, persistent pressure remains on public sector doctors, as does the continued reliance on nurses and primary care to absorb demand.
This suggests a system that is improving, but which continues to operate under structural strain, rather than one that has lost its professional base.
What this indicator can tell us:
whether medical expertise is expanding relative to population,
whether pressure on clinicians is intensifying or easing,
whether outcomes are being achieved despite limited doctor availability.
What it cannot tell us on its own:
quality of care,
geographic distribution,
or productivity differences across facilities.
Figure 9: Number of people per public-sector doctor in South Africa, 2000–2023
(Source: CRA, 2025)
PEOPLE-TO-NURSE RATIO
Nurses constitute the backbone of South Africa’s health system, particularly at primary healthcare level. The people-to-nurse ratio therefore provides a more realistic picture of frontline capacity than doctor counts alone.
The data indicate that nursing capacity expanded meaningfully from the early 2000s through the early 2010s, reflected in a sustained reduction in the number of people per nurse in public hospitals. This improvement reached its strongest point in the mid-2010s, after which the ratio stabilised and, in more recent years, showed modest deterioration, particularly during and after the COVID-19 period. Importantly, however, current levels remain materially better than those observed two decades ago.
This pattern is significant, because many essential health services, including immunisation, maternal care, HIV treatment and chronic disease management, are nurse-led. The evidence therefore suggests that the health system successfully strengthened frontline nursing capacity over time and has since been operating under sustained pressure, rather than experiencing a reversal to earlier stress levels.
While shortages and uneven distribution remain, the trajectory indicates that the system has prioritised nursing output, maintained frontline service capacity, and partially compensated for doctor scarcity.
This helps explain why key outcome indicators in Part I, especially child health and HIV survival, have improved despite broader system pressure.
Figure 10: Number of people per nurse in South Africa, 2000–2023 (public health system)
(Source: CRA, 2025)
PEOPLE-TO-PHARMACIST RATIO
Pharmacists play a critical role in medicine availability, treatment adherence and chronic disease management. Their presence is particularly important in systems managing large numbers of patients on long-term treatment, such as ART and TB therapy.
The data shows that pharmacist capacity has grown significantly over time, though, as with other professional categories, population growth and distribution limit per-capita gains.
The relevance of this indicator lies less in absolute sufficiency than in system viability. Sustained pharmacist capacity supports:
large-scale medicine dispensing,
continuity of treatment,
and the functioning of decentralised care models.
The data therefore suggest that pharmaceutical capacity has improved and been sufficient to support expanded treatment programmes, even if pressure remains high.
Figure 11: Number of public-sector pharmacists in South Africa, 2000–2023
(Source: CRA, 2025)
BEDS IN PUBLIC HOSPITALS
Hospital beds represent static infrastructure capacity and must be interpreted carefully, because beds alone do not treat patients, since they only become meaningful when combined with staff, equipment and referral systems.
The data indicates that the number of beds in public hospitals has remained relatively stable over time and that there has over the last few decades only been limited large-scale expansion thereof, but this reflects fiscal and infrastructural constraints, rather than a withdrawal of hospital service provision.
Stability in bed numbers, when read alongside population growth, increased disease burden and rising demand, implies increasing intensity of use, rather than excess capacity. This finding sets up the efficiency analysis in Part III, particularly bed utilisation and length of stay.
Figure 12: Number of people per public hospital bed in South Africa, 2020–2023
(Source: CRA, 2025)
AMBULANCE SERVICE PROVIDERS
Emergency medical services are a critical, but often overlooked component of health system capacity. One indicator is ambulance availability, which determines whether patients can access care in time, particularly in obstetric emergencies, trauma cases and rural settings.
The data show the presence and distribution of ambulance service providers across provinces and whilst it is true that coverage is uneven and capacity is under pressure, the continued operation and expansion of ambulance services indicates that emergency access mechanisms remain in place.
This is significant for two reasons:
it supports maternal and emergency care outcomes,
it links system capacity directly to time-sensitive survival indicators.
Ambulance services therefore function as a reach indicator, bridging static infrastructure and lived access.
Figure 13: Number of ambulance service provider organisations in South Africa, 2019–2024
(Source: CRA, 2025)
INTERIM OBSERVATION
The capacity indicators presented in this section point to a period of steady strengthening in several core components of South Africa’s health system. Over time, the availability of key health professionals has improved, with fewer people per doctor, nurse, and pharmacist, indicating an expansion in human resource capacity relative to population demand.
These gains in professional capacity have been complemented by improvements in infrastructure and services that are required to support it. Hospital bed availability shows evidence of short-term expansion during the COVID-19 period, followed by stabilisation, while the number of ambulance service providers has increased markedly in recent years, strengthening emergency and pre-hospital care, which trends, taken together, suggest that the health system has expanded its operational footprint across both clinical and emergency response domains.
While these indicators do not speak to distributional equity or service quality, they do establish a clear baseline finding: capacity constraints, though still present in absolute terms, have eased over time across multiple dimensions of the system. The central question therefore shifts from whether capacity has grown to whether existing resources are being deployed efficiently and equitably, an issue addressed in the following section.
PART III
SYSTEM EFFICIENCY AND PERFORMANCE
This part examines how effectively South Africa’s health system converts existing capacity into outcomes. Unlike capacity indicators, which describe what the system has, efficiency indicators reveal how well the system functions under pressure: where bottlenecks emerge, where coordination succeeds or fails and where avoidable loss occurs.
Efficiency does not imply cost-cutting. In this context, it refers to operational performance, how resources, staff, infrastructure and referral systems work together in practice.
BED UTILISATION RATE
Bed utilisation measures the proportion of available hospital beds that are occupied over time. It is a sensitive indicator of system balance.
The data shows that bed utilisation rates in public hospitals are consistently high and they often approach or exceed levels that are normally associated with optimal throughput, which suggests that hospitals in South Africa are neither idle, nor dramatically underused, indeed they are operating close to capacity.
High bed utilisation has two implications: The first being confirmation of the sustained demand for inpatient care; and secondly, it indicates that there is limited slack within the system to absorb shocks or surges.
Importantly, utilisation levels do not point to widespread inefficiency or neglect, but instead, they do reflect a system that is under persistent load, and where capacity constraints are expressed through congestion, rather than abandonment.
Figure 14: In-patient bed utilisation rate in South Africa, 2015/16–2022/23 (%)
(Source: CRA, 2025)
AVERAGE LENGTH OF STAY IN PUBLIC HOSPITALS
The average length of stay captures how efficiently patients move through inpatient care, where shorter stays are indicate of effective treatment and/or discharge planning, whilst longer stays signal clinical complexity, discharge bottlenecks and/or referral breakdowns.
The data shows that the average length of stay in public hospitals has remained relatively stable, with no evidence of dramatic escalation over time, which stability is notable given the high bed utilisation, constrained staffing and increasing disease complexity.
Stable length of stay under such conditions suggests that hospitals have maintained functional throughput, even as pressure has intensified; it does not imply optimal performance, but it does argue against systemic gridlock.
Figure 15: Average length of stay in public hospitals in South Africa, selected years 2008–2022/23 (days)
(Source: CRA, 2025)
INTERIM OBSERVATION
Part 3 assesses health system efficiency using two system-level indicators that capture how hospital resources are utilised and how quickly patients move through inpatient care: in-patient bed utilisation rates and average length of stay. These measures do not describe clinical quality or distributional equity, but they do provide a useful view of operational performance within hospitals.
The evidence indicates that the hospital system is operating within a relatively stable utilisation range, rather than showing a pattern of chronic congestion or sustained under-use, where, for example, bed utilisation levels are sufficiently high to suggest meaningful absorption of available capacity, while also remaining below levels typically associated with persistent overcrowding. This points to a system that, at an aggregate level, is making substantial use of inpatient capacity without signalling structural overload.
Average length of stay provides a complementary view of throughput. Over the period reported, length of stay shows an overall decline from earlier years to more recent years, with some year-to-year variation. A shorter average length of stay is consistent with improved bed turnover and the ability of facilities to treat more patients with a given stock of beds, although the indicator on its own cannot distinguish between efficiency gains and changes in case mix or admission practices.
The appropriate conclusion is therefore bounded and evidence-based. The two indicators together suggest that inpatient services have, in aggregate, maintained stable utilisation while improving throughput over time. They do not, however, allow the report to attribute these changes to specific interventions, nor do they provide proof of programme-level efficiency in areas such as HIV, TB or maternal care. Those issues require additional process and cost measures not examined in this section.
EXPERIENCE VERSUS EVIDENCE: UNDERSTANDING THE PERSISTENCE OF DISSATISFACTION
The evidence presented in this report indicates measurable improvements in several key health outcomes, alongside expanded capacity and stable or improving system-level efficiency, but these findings coexist with a persistent public narrative that the public health system is failing or deteriorating. This apparent contradiction does not imply that the evidence is wrong, rather, it reflects the way health system performance is experienced and perceived at the point of care.
Health system outcomes are measured at aggregate level, while health system experience is local, uneven and intensely personal. Improvements in national averages do not eliminate the reality that patients encounter long waiting times, overcrowded facilities, staff shortages and variable quality in specific hospitals or clinics. Where service delivery fails, it does so visibly and directly, shaping public perception far more powerfully than incremental or preventative successes that are, by their nature, less visible.
In addition, improvements in health outcomes often manifest as non-events, such as lives not lost, infections averted, conditions managed before becoming catastrophic, yet these gains are real and substantial, even if they are largely invisible to the individual users of the system. By contrast, service failures are highly salient, where a delayed ambulance, an overcrowded ward and/or an unavailable specialist is immediately experienced and remembered, thereby reinforcing a sense of systemic dysfunction even in the presence of broader improvement.
The persistence of dissatisfaction should therefore be understood not as evidence that the system has failed to improve, but as a reflection of the distributional strain in the health system, uneven service quality and the inherent visibility bias associated with public services. System-level progress can coexist with poor individual experiences, particularly in a context of high demand, historical inequality and constrained resources.
Recognising this distinction is essential. It allows the report to acknowledge lived experience without dismissing it, while also avoiding the error of conflating perception with aggregate performance. The evidence and the experience are not mutually exclusive, they describe different dimensions of the same system. Understanding both is necessary for an honest assessment of where South Africa’s health system has improved, where it remains under pressure, and why public confidence lags behind measured progress.
What this report does not claim
This report is intentionally narrow in scope and evidentiary ambition. It does not claim that South Africa’s public health system is adequately resourced, equitably distributed or free from serious operational failures. Nor does it deny the persistence of service breakdowns, staff shortages, infrastructure decay or uneven patient experience across provinces and facilities.
The analysis does not seek to evaluate health policy design, governance arrangements or reform proposals such as National Health Insurance, nor does it assess the efficiency or integrity of procurement, management or oversight structures. It also does not attempt to measure quality of care at the point of service, patient satisfaction or institutional culture.
Instead, the report confines itself to a limited, but important question: whether key population-level health outcomes and system capacity indicators are broadly consistent with the claim that the public health system has experienced wholesale collapse. The findings suggest a more complex reality, one characterised by measurable gains over time, followed by sustained strain and uneven performance, rather than systemic failure across all dimensions.
By drawing this distinction explicitly, the report aims to inform debate, rather than settle it, and to ground public discussion in evidence without minimising lived experience or legitimate dissatisfaction. |
CONCLUSION
This report set out to assess whether South Africa’s public health system shows evidence of progress when examined through outcomes, capacity and efficiency, rather than through anecdote or isolated failures. On balance, the evidence supports a measured, but defensible conclusion: important aspects of health performance have improved over time, even as significant challenges and vulnerabilities remain.
At the level of health outcomes, the data explored in this report does not sustain a narrative of systemic deterioration. Long-run declines in infant and child mortality, which if read alongside the improvements in life expectancy, points to a better survival rate across key stages of the life course. Most notably, the sustained reduction in new HIV infections and the marked decline in tuberculosis prevalence since the early 2010s indicate a structural shift away from the exceptionally high disease burdens that characterised the height of the HIV epidemic. These improvements are neither uniform nor are they complete, but they are substantial, durable and observable across multiple independent health performance indicators.
The assessment of health system capacity shows that these outcome improvements have not occurred in isolation, but over time, within a system that has expanded critical inputs, including health personnel, infrastructure and emergency services. While capacity remains uneven across regions and services, and while shortages persist in key areas, the aggregate trend is one of expansion, rather than contraction. This provides an essential context for interpreting outcomes: the system has been required to deliver care to a growing and ageing population under sustained epidemiological and fiscal pressure.
The evidence on efficiency, that this report examined through in-patient bed utilisation rates and average length of hospital stay, points to a cautious, but meaningful improvement in operational performance within hospitals, where utilisation levels suggest that available inpatient capacity is being actively used without clear signs of chronic overload, while declining lengths of stay are consistent with improved throughput. These indicators are necessarily limited in scope and do not speak to quality of care or programme-level efficiency. Nonetheless, they provide credible evidence that the system has, in aggregate, managed to maintain or improve operational functioning, rather than deteriorate under pressure.
Taken together, the findings challenge both extremes of the public debate, in that they do not support complacency, nor do they justify claims of wholesale failure, and instead, the evidence points to a health system that has made real progress, particularly in outcomes related to communicable diseases, while continuing to operate under significant structural and distributional constraints.
The implications are clear. First, policy debate should be grounded in evidence that recognises both progress and limits, rather than defaulting to crisis narratives; second, future reform efforts should focus less on blanket assessments of system failure and more on identifying where gains have been made and how they can be consolidated and extended; and finally, while the system has demonstrated resilience and adaptive capacity, sustaining and deepening these gains will require continued investment, targeted reform and careful attention to efficiency, equity and quality.
In short, the South African public health system emerges from this assessment not as a system in collapse, but rather, as one that has delivered meaningful improvements over time under difficult conditions, a reality that should inform both the public discourse and the policy choices going forward.
REFERENCES
Centre for risk Analysis (CRA). 2025. Socio-Economic Survey of South Africa. Health February 2025.[Online] Available at: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://cra-sa.com/products/socio-economic-survey/2025/files/health-february-2025-02.pdf [accessed: 20 January 2026]
Statistics South Africa (SA). 2024. Mid-year Population Estimates, 2024 (Statistical Release P0302), Appendix 2 (Demographic indicators, 2002–2024). [Online] Available at: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.statssa.gov.za/publications/P0302/P03022024.pdf? [accessed: 20 January 2026]
ANNEXURE A
DATA TABLES SUPPORTING THE ANALYSIS
This annexure contains the underlying health outcome, system capacity and efficiency data series referenced in the report. The tables are provided to enable readers to verify reported figures, examine trends over time, and replicate the analysis presented in the main body of the report.
The data cover indicators relating to population health outcomes, health system inputs and selected measures of system utilisation. All series are drawn from the sources cited in the report and are presented without adjustment or modelling, unless explicitly stated.
PART I: QUALITATIVE IMPROVEMENTS IN HEALTH OUTCOMES
Year | Vaccination coverage in children (%) | Infant mortality (under 1 year) per 100k | Under-five mortalitYeary rate per 100k | Life expectancy at birth (yrs) | Acute malnutri-tion (%) | No. of HIV-positive people (%) | New HIV infections (number) | TB prevalence (per 100k) |
1990 | 475 | |||||||
1991 | 475 | |||||||
1992 | 473 | |||||||
1993 | 461 | |||||||
1994 | 444 | |||||||
1994 | 427 | |||||||
1996 | 415 | |||||||
1997 | 417 | |||||||
1998 | 443 | |||||||
1999 | 496 | |||||||
2000 | 568 | |||||||
2001 | 644 | |||||||
2002 | 57 | 79,7 | 14,4 | 694 | ||||
2003 | 57,1 | 82,3 | 14,8 | 722 | ||||
2004 | 57,2 | 81,3 | 15,1 | 736 | ||||
2005 | 56,2 | 80,9 | 15,3 | 748 | ||||
2006 | 55,1 | 78,2 | 15,5 | 748 | ||||
2007 | 49,4 | 70 | 15,7 | 753 | ||||
2008 | 48,9 | 63,8 | 15,9 | 761 | ||||
2009 | 44,7 | 55,9 | 16,1 | 380402 | 795 | |||
2010 | 41,9 | 50,6 | 16,5 | 803 | ||||
2011 | 37,1 | 44 | 16,8 | 320995 | 831 | |||
2012 | 34,6 | 40,4 | 17,2 | 857 | ||||
2013 | 32,9 | 38,5 | 17,5 | 283764 | 715 | |||
2014 | 30,9 | 37,4 | 17,6 | 696 | ||||
2015 | 29,2 | 36,7 | 17,6 | 253300 | 454 | |||
2016 | 28,2 | 36,2 | 17,6 | 438 | ||||
2017 | 27,3 | 35,7 | 17,6 | 211955 | 322 | |||
2018 | 76,6 | 25,6 | 33,4 | 7,4 | 17,6 | 301 | ||
2019 | 83 | 25,4 | 32,5 | 7,1 | 17,5 | 181376 | 360 | |
2020 | 84,5 | 24,5 | 31,4 | 7,8 | 17,3 | |||
2021 | 82,7 | 24,5 | 31,3 | 7,3 | 17,2 | 163906 | ||
2022 | 87,6 | 24,9 | 31,2 | 7,9 | 17 | |||
2023 | 83,5 | 24 | 30,5 | 7,2 | 16,9 | 149277 | ||
2024 | 22,9 | 28,6 | 16,7 | 141808 |
PART II: HEALTH SYSTEM CAPACITY
Year | People-to-doctor | People-to-nurse | People-per-pharma-cist | Number of public hospital beds | Number of ambulance providers |
1990 | |||||
1991 | |||||
1992 | |||||
1993 | |||||
1994 | |||||
1994 | |||||
1996 | |||||
1997 | |||||
1998 | |||||
1999 | |||||
2000 | 3808 | 482 | 40263 | ||
2001 | 4015 | 491 | |||
2002 | 4143 | 496 | 35908 | ||
2003 | 4186 | 509 | 37995 | ||
2004 | |||||
2005 | 3829 | 492 | 28997 | ||
2006 | 3584 | 490 | |||
2007 | 3428 | 480 | 26148 | ||
2008 | 3317 | 466 | 26275 | ||
2009 | 3247 | 464 | |||
2010 | 3174 | 450 | 16855 | ||
2011 | 3112 | 423 | 14583 | ||
2012 | 3036 | 424 | 13400 | ||
2013 | 2867 | 407 | |||
2014 | 2921 | 408 | |||
2015 | 2948 | 411 | 11058 | ||
2016 | 2978 | 418 | 10704 | ||
2017 | 2862 | 420 | 10457 | ||
2018 | 2911 | 425 | 10522 | ||
2019 | 3051 | 440 | 11453 | 713 | |
2020 | 2936 | 446 | 11173 | 85063 | 736 |
2021 | 2760 | 415 | 10850 | 55913 | 734 |
2022 | 2735 | 422 | 10491 | 88556 | 760 |
2023 | 2795 | 446 | 10436 | 88785 | 797 |
2024 | 834 |
PART III: SYSTEM EFFICIENCY AND PERFORMANCE
Year | Bed utilisation rate | Average length of stay (days) |
1990 | ||
1991 | ||
1992 | ||
1993 | ||
1994 | ||
1994 | ||
1996 | ||
1997 | ||
1998 | ||
1999 | ||
2000 | ||
2001 | ||
2002 | ||
2003 | ||
2004 | ||
2005 | ||
2006 | ||
2007 | ||
2008 | 6,4 | |
2009 | ||
2010 | ||
2011 | ||
2012 | 6,6 | |
2013 | ||
2014 | 6,5 | |
2015 | ||
2016 | 72 | 6,2 |
2017 | 70,6 | |
2018 | 67,7 | 6,2 |
2019 | 72,5 | 6 |
2020 | 72,4 | 6,1 |
2021 | 60,7 | 5,9 |
2022 | 65,9 | 6,1 |
2023 | 66,9 | 6,2 |
2024 |
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This report has been published by the Inclusive Society Institute
The Inclusive Society Institute (ISI) is an autonomous and independent institution that functions independently from any other entity. It is founded for the purpose of supporting and further deepening multi-party democracy. The ISI’s work is motivated by its desire to achieve non-racialism, non-sexism, social justice and cohesion, economic development and equality in South Africa, through a value system that embodies the social and national democratic principles associated with a developmental state. It recognises that a well-functioning democracy requires well-functioning political formations that are suitably equipped and capacitated. It further acknowledges that South Africa is inextricably linked to the ever transforming and interdependent global world, which necessitates international and multilateral cooperation. As such, the ISI also seeks to achieve its ideals at a global level through cooperation with like-minded parties and organs of civil society who share its basic values. In South Africa, ISI’s ideological positioning is aligned with that of the current ruling party and others in broader society with similar ideals.
Email: info@inclusivesociety.org.za
Phone: +27 (0) 21 201 1589
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