Many South Africans live carefully curated lives. Private schools. Medical aid. Gated estates. Armed response. If the public system fails, the thinking goes, we simply step around it.
It is an understandable instinct. When public services feel unreliable, those who can afford to do so build private alternatives.
Over time, this begins to feel like independence – proof that you have “made it”, that you are no longer exposed to the risks everyone else must endure.
But health does not work that way. Unlike schooling or security, healthcare is not something you can fully opt out of. It is a complex system – dependent on people, infrastructure, regulation, training pipelines and emergency response capacity when natural disasters and pandemics strike – most of which sit firmly in the public domain, whether we acknowledge it or not.
The uncomfortable truth is this: South Africa’s private healthcare system is not a parallel universe. It is a dependent subsystem, built on public foundations that are showing serious cracks. Consider the people who keep the system running. Doctors, nurses, paramedics, psychologists and pharmacists. Almost all are trained in public institutions.
Many begin their careers in public hospitals. Even those working exclusively in private practice rely on public systems for specialist training, accreditation, emergency overflow and disease surveillance. When those pipelines weaken, the effects are delayed, but inevitable.
South Africa already sits well alarmingly below international benchmarks for health professionals per capita. The World Health Organisation estimates a minimum density of doctors, nurses and midwives needed to deliver basic health services. We fall short of that threshold – and the gap is widening. Emigration, burnout, early retirement and poor workforce planning are draining skills faster than we replace them.
This does not announce itself dramatically. It shows up quietly: longer waiting times for specialists and elective procedures, fewer practitioners taking on complex cases, emergency departments stretched thin, medical aid premiums always rising faster than inflation. Eventually, it shows up as something more disturbing – care that is available in theory, but not in practice.
Mental health offers a particularly stark example. South Africa has some of the highest rates of trauma exposure in the world, driven by violence, injury, poverty and inequality. Yet, access to mental health care is limited. There are simply not enough psychiatrists, psychologists and trained counsellors to meet demand. Medical aid does not conjure professionals into existence. It only pays the ones who are already overwhelmed.
Violence and injury tell a similar story. Road crashes, interpersonal violence and unsafe environments generate a constant flow of emergencies – the kind that do not ask whether you have medical aid before they arrive. Trauma units, intensive care beds and rehabilitation services are shared national resources. When they are overloaded, everyone feels it.
Countries with strong private health sectors but weak public systems eventually face the same pattern: escalating costs, declining access, and growing inequity – not because private care is inherently flawed, but because it cannot function without a stable public backbone.
The middle class often underestimates this risk because system failure is slow – until it isn’t. It accumulates quietly, in workforce shortages and neglected infrastructure, until a shock exposes the fragility.
Health systems are not luxury apartments where you can simply move to a better floor. They are load-bearing structures. If the foundation weakens, the penthouse is not immune.
This is why public health should matter to everyone, not only to those who rely exclusively on state services. Silence from those who have insulated themselves financially has consequences. It signals that deterioration is acceptable, that decline can be managed privately, that collective risk is someone else’s problem. It isn’t.
The question facing South Africa is no longer whether the public health system is under strain – that is beyond dispute. The real question is whether enough people who still feel protected are willing to engage before the effects become unavoidable.
This column will return to these issues regularly: the health workforce crisis, access to mental health care, violence and injury as health system failures, and the slow erosion of capacity that affects us all. Not to assign political blame, but to ask harder questions about shared responsibility. Health matters. Not as a slogan, but as a system we all depend on – whether we admit it or not. And it is time we started talking about it.
• Dr Wolvaardt is CEO of the Foundation for Professional Development, a leading institution for health-related education, research, and leadership development.
