Health Minister Dr Aaron Motsoaledi recently told South Africans that the public healthcare system’s failures stem from a decade of “austerity”. He repeated this word, deliberately, five times in one sentence. It is a memorable line. However, it’s not a claim the data support.
Consolidated national and provincial health expenditure grew from R144.2 billion in 2014/15 to R267.3 billion in 2023/24, and National Treasury predicts that it will reach R310.8 billion by 2027/28. In real terms, public health spending more than doubled since 2000, from 2.7% of GDP to a peak of 5.3% in 2020, settling at 5.0% in 2021. Public health spending as a share of total government expenditure rose from 11.9% in 2000 to 15.3% in 2021, a level it has held since roughly 2015. None of this describes a sector being starved of resources.
South Africa’s health spending also compares favourably with that of its peers. In 2021, the country spent 8.3% of GDP on health, more than Nigeria, India, China and most emerging markets, and public expenditure made up 60.4% of that total, a higher public share than those in Switzerland, the United States and Egypt.
Out-of-pocket spending in South Africa, at 5.5% of total health expenditure, is among the lowest in the world. Whatever else ails the public health system, a refusal by the state to fund it is not supported by the data.
Staffing and infrastructure numbers point the same way. The number of public sector general practitioners and specialists rose from 11,472 in 2000 to 22,245 in 2023, an increase of 93.9%. The ratio of people to public sector doctors improved from 3,808 to 1 in 2000 to 2,795 to 1 in 2023. Public sector nurse numbers rose from 90,654 to 143,521 over the same period, improving the people-to-nurse ratio from 482 to 1 to 422 to 1.
The number of public hospital beds increased by 4.4% between 2020 and 2023 alone. Outcomes reflect this: the infant mortality rate fell from 57.0 per 1,000 live births in 2002 to 22.9 in 2024, and the under-five mortality rate fell from 79.7 to 28.6 over the same period, a decline of 64.1%.
Set to fall
This doesn’t mean the minister’s underlying complaint is baseless. Compensation of employees consumed 64.0% of health expenditure in 2023/24, leaving only 29.2% for goods and services: the actual medicines, equipment and consumables that keep clinics functioning. Consolidated health expenditure’s share of total government spending is set to fall from 12.4% in 2021/22 to 11.2% by 2027/28, a real squeeze relative to other priorities, even as nominal rand amounts rise.
The total number of registered medical students fell by 40.2% between 2021 and 2022, from 19,922 to 11,916, a collapse that has only partially reversed since. These are legitimate, quantifiable problems. But they are not the same problem as “austerity” and conflating the two obscures what needs fixing.
The minister’s own diagnosis, delivered in the same remarks, of weak procurement, poor financial management and neglected maintenance, is closer to the truth than his framing suggests. For years the Auditor-General has flagged irregular expenditure in provincial health departments running into tens of billions of rand. Money has been available. Whether it reached the front line as medicine on a shelf or a functioning generator is a separate question. It is a question of ideology, policies, and legislation, one of institutional capacity and control, not of Treasury’s willingness to fund the sector.
Ideology, policies and legislation explain more of this pattern than any Treasury circular does.
Being squeezed
Preferential procurement rules under the Public Procurement Act and the B-BBEE framework add costs and delay to the purchase of medicines, equipment and building-maintenance contracts, the very goods-and-services category the minister says is being squeezed. Provincial health departments have, for years, left funded posts vacant while imposing hiring moratoria, not because Treasury withheld the money but because compensation ceilings and internal budgeting choices left no room to fill them.
Cadre deployment into administrative and supply-chain positions in provincial health departments has repeatedly surfaced in Auditor-General findings and in the Zondo Commission’s record as responsible for the very procurement failures Mr Motsoaledi named. The clearest illustration remains Life Esidimeni.
Money had been allocated; facilities existed. But governance failed, oversight failed, and 144 psychiatric patients died in Gauteng in 2016, a scandal produced entirely by decisions taken inside a well-funded department. That is the pattern repeated in hospital-maintenance backlogs and empty pharmacy shelves today, and it has nothing to do with austerity.
This also explains why the National Health Insurance (NHI), the minister’s own proposed remedy, will not cure what he describes. The NHI proposes to centralise the purchasing of health services worth hundreds of billions of rand into a single fund, administered by many of the same institutions and personnel whose procurement, financial management and maintenance failures Motsoaledi has just described.
Concentrating that much purchasing power in one entity does not fix weak internal controls. It raises the stakes attached to them. A department that cannot maintain a hospital roof or stock a pharmacy shelf under the current system will not become more competent by being handed a bigger budget and a wider procurement mandate.
Whatever else the NHI achieves, it is not a fix for the capacity and governance problems the minister himself identified.
Legitimate debate
There is a legitimate debate to be had about whether compensation growth is crowding out operational spending, about whether the R20.9 billion allocated over three years is adequate, and about the effect of the RWOPS review the minister has announced.
Blaming “austerity” closes that conversation before it starts. If the sector’s problems were simply a matter of money, doubling real public health spending since 2000 should have solved them. It has not, because the deeper problems lie in how provinces manage the money they already have. Centralising that money into a single fund will not solve them either.
[Image: by SteveAllenPhoto999]
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