Health Ombudsman's Report Points to Need for Urgent Reforms in South Africa's Healthcare System

Many have concluded that South Africa's public healthcare system has collapsed, and this conclusion is understandable given the personal experiences of many citizens. However, available data suggests a more complex picture.

Problems and Service Reality

It cannot be argued that South Africa's healthcare system functions perfectly. In fact, the quality of services provided in many institutions remains unacceptably low. Every day, millions of South Africans face serious problems such as long waiting times, overcrowding, staff shortages, and administrative failures. At the same time, the disappointment and humiliation often accompanying such experiences cannot be underestimated.

The Difference Between Struggle and Collapse

However, there is a fundamental difference between a system that is struggling and a system that is in complete collapse. The question is not whether patients experience frustration—it is obvious that they do. The main question is whether the population's health indicators are deteriorating. On this metric, the evidence points convincingly in the opposite direction.

Significant Health Improvements

Consider the trend in child mortality over the last two decades. In 2002, approximately 57 infants died per 1,000 live births in South Africa. By 2024, this figure had dropped to less than 23. A similar trend was observed regarding the mortality of children under five: it fell from nearly 80 deaths per 1,000 live births to less than 30 over the same period. These figures reflect the survival of hundreds of thousands of children who might not have survived to adulthood a generation ago.

A similar positive trend is visible in life expectancy. At the peak of the HIV/AIDS crisis, South Africans lived and died sooner than at any point in the democratic era. In 2002, the average life expectancy was less than 55 years, whereas today it exceeds 66 years. This means that the average resident of South Africa can expect to live more than a decade longer than twenty years ago. Life expectancy is one of the most comprehensive indicators of a nation's health status, and in this aspect, South Africa has made significant progress.

Epidemic Control

Part of this can be explained by the country's response to the most serious public health challenges. For example, the number of new HIV cases decreased from over 380,000 per year at its peak in the late 2000s to approximately 142,000 in 2024, representing a decrease of more than 60%. Furthermore, tuberculosis prevalence declined after peaking at about 857 cases per 100,000 people, which was reached after rising from approximately 475 cases per 100,000 in 1990. These changes rarely become the central topic of public discussion, but they are among the most important achievements in public health during the democratic period.

The Paradox of Quality and Outcomes

Critics rightly argue that these statistics do not align with their personal experiences, pointing to overcrowded hospitals, drug shortages, and facilities that seem unable to cope with the load. They assert that patients experience healthcare through the lens of the quality of the service received, rather than through national averages and long-term trends. This observation is absolutely correct.

However, this does not negate the existing evidence. On the contrary, it highlights an important distinction: service quality and health outcomes are related, but they are not the same thing. A patient may face unacceptable waiting times in a clinic but still benefit from a system that has proven more effective in preventing child mortality than twenty years ago. A hospital may suffer from managerial failures but nevertheless contribute to increased life expectancy and improved disease outcomes. These realities do not exclude each other.

Conclusion on the Healthcare System

This may be the central paradox of South Africa's healthcare: the system delivers better results than many realize while providing a level of service that often falls short of reasonable expectations. The mistake of government supporters is focusing exclusively on positive indicators while ignoring daily patient dissatisfaction. The mistake of pessimists is concentrating only on these frustrations and neglecting the measurable improvements that have occurred over time. Neither approach serves the public interest.

Sound policy begins with accurate diagnosis. If we assume everything is collapsing, we risk missing interventions that have proven effective and abandoning approaches that have saved lives. Conversely, if we become complacent due to positive trends in some indicators, we risk entrenching an unacceptable level of service provision. The evidence points to a more nuanced conclusion: South Africa's healthcare system is under significant pressure, often inefficient, and regularly causes dissatisfaction among those who depend on it, but it is not in a state of collapse.

As the next municipal elections approach in November, a serious threat looms over South Africa's democratic landscape in the form of an ongoing service delivery crisis. Despite thirty-two years of democracy, residents across the country face fundamental issues concerning water supply, sanitation, electricity, and infrastructure.

Demands on Political Parties

Dr. Uduak Johnson, head of the academic programme at MANCOSA School of Public Administration, stressed the urgent need for political parties to focus on practical and achievable measures ahead of the elections. He argues that the elections are a moment of accountability, and candidates must not just promise service improvements but clearly explain how they will ensure reliable, sustainable, and responsive governance for communities.

Access Improvements and Reliability Issues

Statistical data to be presented in the upcoming 2025 Household Survey by Stats SA shows improvements in access over the last two decades: access to improved sanitation rose from 61.7% in 2002 to 84.0% in 2025, and household connection to the centralized electricity grid increased from 76.7% to 90.6%. However, these figures mask a deeper problem: municipalities are struggling to ensure the stability and reliability of delivered services.

For instance, access to piped water has improved marginally, but in several provinces—including Limpopo, Mpumalanga, Free State, and Gauteng—these indicators have declined. In Limpopo alone, access dropped by 10.6 percentage points during this period. Combined with deep spatial inequality, evident in the stark contrast in waste removal services—84.9% in urban areas versus only 13.0% in rural municipalities—the need for reform becomes extremely clear.

Governance as the Main Problem

This crisis is not limited to infrastructure; it also points to significant challenges in governance and local government capacity. According to the latest Auditor-General report, only 41 out of South Africa's municipalities—just 16%—have passed a clean audit, with improvements either stalling or, in some cases, reversing. Municipalities face numerous obstacles, such as weak financial management, irregular spending, and vacancies in key technical positions.

Dr. Tandile Ntswana, also from MANCOSA, believes that fixing the service delivery situation goes beyond simply increasing funding; municipalities need to develop robust internal management systems and ensure professional and accountable administration. He warns: 'Without the necessary skills and structural improvements, service delivery improvements will remain unattainable.'

Declining Trust in Government

The situation is exacerbated by a significant decline in public trust. The Afrobarometer report from June 2026 showed that only 17% of South Africans felt that local councillors often listened to their constituents. Dissatisfied respondents reported even greater frustration, noting that 67% of the time their votes are ignored. This skepticism has turned local government into one of the least reliable institutions in the country, deeply affecting citizen participation in democratic processes.

Dr. Johnson notes: 'When communities face repeated service failures without recourse or accountability, faith in democratic institutions erodes.' The upcoming elections represent a crucial opportunity for citizens to demand accountability and change based on transparency and deliverable service commitments.

The Path to Real Reforms

MANCOSA School of Public Administration emphasizes the necessity for municipalities to prioritize visible and measurable improvements in service delivery. Immediate action must be taken to fix leaking pipes, resolve sewage overflow issues, and restore regular waste collection schedules. These tangible actions can help rebuild public trust and strengthen residents' faith in their local authorities.

As the election campaign intensifies, political parties are urged to develop specific service delivery plans for each municipality, rather than relying on general manifestos. Voters should question candidates about priorities in solving pressing issues such as water shortages and power outages. It will be critical for political parties to demonstrate accountability through clear targets, public reporting deadlines, and mechanisms ensuring councillors are held responsible for their actions after the elections.

Call to Action

Academics argue that the time for political rhetoric is over; actions must speak louder than words. As South Africa prepares for the upcoming local government elections, the urgency of resolving service delivery problems cannot be overstated. While long-term reforms are vital, the immediate need for visible improvements in daily governance must remain a priority.

Only through accountability, professional administration, and well-designed service delivery plans can South Africa begin to overcome its protracted service crisis. The future depends on those who prioritize not just promises, but real improvements that are felt in the daily lives of South Africans.