Gauteng may need far more than the 15 820 nurses reflected in official estimates because the public hospital organograms used to determine staffing levels have not been reviewed since 2006, the chairperson of the provincial legislature's health committee has warned.
Advocate Ezra Letsoalo, chairperson of the Gauteng Legislature's Health and Wellness Portfolio Committee, said the approved staff establishments no longer reflected population growth or the pressure on hospitals and clinics.
The last review of public hospital organograms was conducted in 2006. Gauteng now has more than 16.1 million residents, while its public health facilities recorded about 19.1 million patient visits in 2025, according to figures cited by Letsoalo.
"The 15 000 can only be accounted for against the current obsolete organogram," he said. Nursing stakeholders who engaged with the committee believed the real requirement could be as much as three times the department's estimate, although that figure has not been independently established.
Letsoalo said staffing was the most serious concern emerging from the committee's visits to hospitals, clinics and specialist facilities.
An obsolete staffing model
The Gauteng Department of Health operates about 372 clinics and 40 provincial hospitals. Its presentation to the committee on 11 September listed 2 272 funded nursing vacancies and a further 1 186 vacant posts for which funding was unavailable. Filling the unfunded posts alone would cost an estimated R607.8 million.
Under proposed staffing norms, the department calculated a shortage of 15 820 nurses across categories including professional general nurses, specialist nurses, enrolled nurses, nursing assistants, primary healthcare and nursing management.
Organograms determine how many positions a facility may fill. A hospital can therefore fill every approved post and still be understaffed if its establishment is based on demand from 20 years ago.
Letsoalo said this weakened the system's ability to respond to patients and compromised the coordination, efficiency and quality of care. He cited casualty units where two doctors could be expected to manage a stream of emergency cases.
"If you don't have proper data analytics on the number of patients who interface with your facilities, you are likely to undermine and hinder the ability of the system to be adequately responsive," he said.
What the shortage means for patients
The department has acknowledged that workloads have doubled in some areas. Nurses work extended hours and sometimes miss meal and tea breaks. Its presentation linked the shortage to longer waiting times, low morale, burnout, missed or inconsistent care and more patient-safety incidents.
Letsoalo said too few nurses could disrupt every stage of a patient's visit, from opening a file and being triaged to seeing a doctor, undergoing diagnostic tests and receiving medicine. An administrative step that should take about 20 minutes could stretch beyond an hour before clinical care had even begun.
Nurses working under these conditions face burnout and anxiety, increasing pressure across the facility. But Letsoalo stopped short of describing Gauteng's health system as unsafe.
"The system is still functional and still responsive, but it is taking strain," he said. Describing it differently could understate the gravity of the situation and delay interventions, he added.
Mental-health facilities illustrate the problem. Committee visits found too few psychiatric and rehabilitation nurses, overcrowding, deteriorating buildings and shortages of step-down and community placements. At Dr George Mukhari Academic Hospital's mental-health unit, the committee recorded high numbers of patient-safety incidents and nursing ratios of one nurse to six stable patients and one to four acute patients.
Training and retention have not kept pace
Letsoalo said the province was also struggling to bring younger nurses into a workforce in which many experienced professionals are approaching retirement. He questioned whether current training equipped graduates for the complexity of Gauteng's public hospitals.
Newly qualified nurses could complete three- or four-year programmes without the specialised skills most urgently required, he said. These include midwifery, mental health, critical care, neonatal and theatre nursing.
The Gauteng College of Nursing is accredited to train 500 general nurses and 415 specialist professional nurses annually. The department's table recorded no annual places for enrolled nurses or nursing assistants, despite projected shortages of 4 375 and 3 395 respectively in those categories.
Letsoalo called for a review of nursing curricula, particularly where graduates entered demanding facilities without midwifery or other specialist capabilities. Complex pregnancies and South Africa's combined burden of communicable and non-communicable disease required a broader mix of skills, he said.
Yet 2 272 funded posts remain vacant. Letsoalo attributed this to national austerity measures, slow recruitment, administrative weakness and difficulty retaining nurses in the public sector.
Pay and career progression are part of the problem. The occupation-specific dispensation for nurses was introduced in 2007 and was due for review five years later, in 2012. That review has still not taken place. The department says the delay has contributed to poor morale, staff losses and difficulty attracting experienced nurses.
Letsoalo said some nurses could no longer meet their living costs because their remuneration had not kept pace. The failure to update a measure originally intended to retain scarce skills had made public-sector nursing less attractive, he said.
Gauteng Health proposes asking the provincial treasury to unfreeze posts, introducing a differentiated wage bill and recruiting newly qualified nurses within six months of their registration with the South African Nursing Council. It also wants a five-year workforce plan and a provincial strategy for nursing and midwifery.
To cover immediate gaps, the department uses overtime in specialised units and private nursing agencies. Its presentation did not state how much the agency arrangements would cost or how many vacancies they were expected to cover, leaving their contribution to the broader shortage unclear.
From monitoring to consequences
The Gauteng Provincial Legislature does not run hospitals. Its four mandates are law-making, oversight, public participation and cooperative governance. The health committee examines budgets and performance, questions officials and visits facilities to hold the department accountable.
Letsoalo said clinical investigations should determine what happened when understaffing contributed to harm, but responsibility did not end with individual practitioners. "Ultimately, the buck stops with the executive authority of the department," he said.
The committee has asked for a monitoring framework with measurable targets, deadlines, responsible officials and regular reports. Letsoalo said it should identify who was responsible when commitments were not met.
He said provincial oversight alone was insufficient because health funding and workforce policy also depended on national decisions. Gauteng had raised the problem with Parliament's health structures and wanted closer coordination between provincial legislatures, the National Assembly and the National Council of Provinces.
The committee wants visible improvements within the next year: shorter waits, better patient experiences, more nurses, safer mental-health facilities, reliable medicine supplies and greater investment in infrastructure. Achieving that will require the department to fill funded posts, revise obsolete organograms and show what action follows when officials miss deadlines.
The shortage also presented a serious risk to National Health Insurance, Letsoalo said. "It is a real risk. It is not imagined or perceived," he said. NHI could not deliver better health outcomes without enough nurses, doctors and specialists to provide care.
"We need to go beyond just diagnosing what the problems are," he said. "Beyond monitoring, you need action. There should be corrective actions and remedial interventions."