Living Between Two Healthcare Systems: Reflections from a Rural Family Physician

South Africa has a two-tier healthcare system consisting of both public and private services. Approximately 14–15% of South Africans belong to a medical aid scheme, while the remaining 85% rely on the public health sector.

I work one day a week as a family physician in a government clinic in a small coastal town in the Western Cape. The town has around eight private general practitioners and a private emergency medical service. The public sector consists of a primary healthcare clinic staffed mainly by clinical nurse practitioners, with a visiting doctor available three days a week.

One of the realities I encounter daily is that many patients without medical aid move between the two systems rather than using only one. Although there has been considerable investment in public healthcare over the years, there remains a widespread perception that private care is inherently better.

It is common for family members to pool their resources so that a loved one can have a once-off consultation with a private GP or specialist. Patients often obtain their chronic medication through the public clinic but seek private care when they develop an acute illness or when they feel they need faster access to a doctor. They may also go private to obtain prescriptions for medicines that are not available in the public sector.

Patients using the public system face challenges. Patients are usually first assessed by a clinical nurse practitioner before seeing a doctor, and waiting times can be long. On the other hand, patients paying privately often cannot afford chronic medications and investigations such as blood tests, X-rays, CT scans or MRI scans. Major surgical procedures, such as joint replacements, are beyond the financial reach of many families, and these patients inevitably return to the public sector for definitive treatment.

Recently I cared for a patient whom I have known for several years. He had previously undergone surgery for cancer in a government hospital and remained in remission for four years. When he developed progressively worsening back pain over several months, the earliest appointment available in the public system was two months away.

Desperate for answers, he consulted a private specialist, who arranged an MRI scan. The scan confirmed that his cancer had recurred. He was referred to a private oncologist where he received a single course of palliative radiotherapy and was started on hormone therapy—all at considerable personal expense. He was unsure of his further treatment plan and prognosis and could not afford to pursue further private treatment.

When returned to the local government clinic, I was able to facilitate an earlier appointment at the oncology department of our tertiary public hospital. He was seen within a month, where the oncology team carefully reviewed his condition and explained that further chemotherapy would not provide meaningful benefit. He left that consultation feeling reassured, not because he received more treatment, but because he finally understood his situation and the way forward.

He hopes to continue the hormone therapy privately for as long as he can afford it.

This patient's journey reminded me that, for many South Africans, healthcare is not simply a choice between public and private. It is a constant balancing act between affordability, accessibility and hope. Patients navigate both systems as best they can, seeking timely care where they can find it and returning to the public sector when costs become overwhelming.

Working in both settings has taught me that each system has its strengths and its limitations. The real challenge is not deciding, which is better, but finding ways for them to complement one another so that patients receive the care they need, regardless of who pays for it.

How does this compare with your experience? If you work in healthcare, do your patients also move between public and private care? What lessons have you learned from practicing across both systems?