His specialist interest in placental and fetomaternal pathology developed after encountering repeated pregnancy losses without clear explanations. He undertook additional training through American and Canadian programmes after concluding that placental examination was receiving insufficient attention in local practice.

Reflecting on his specialist focus, Dr Nhlonzi points to a consistent gap in practice:
“I felt that in our setting, we’re not giving enough attention to the placenta, which forms an integral part of the developing fetus.”

Two Systems, Different Diagnostic Timelines  

Having worked in both sectors, Dr Nhlonzi describes a marked contrast in how quickly diagnoses are reached.

In the private sector, he has seen patients receive biopsies promptly, with pathology results returned within predictable timeframes and treatment initiated without prolonged delay. In some cases, early diagnosis has enabled long-term surveillance and the detection of subsequent disease.

The public sector operates under different constraints. Delays can occur at multiple points in the diagnostic pathway, including specimen transport, laboratory processing, and reporting capacity. By the time a definitive diagnosis is reached, the disease may already have advanced.

The consequences of delay are often stark. “By the time it’s time for definitive treatment, the patient is already having metastatic disease.”

Capacity, Workload, and Trade-offs  

The uneven distribution of pathologists compounds these delays. In KwaZulu-Natal, Dr Nhlonzi notes that private sector pathologists significantly outnumber those working in the public system, despite the public sector serving the majority of patients.

Public sector pathologists are required to balance high diagnostic volumes with teaching, research, and participation in clinical meetings. The cumulative nature of this workload, he explains, creates unavoidable trade-offs.

“Somewhere, somehow, the quality probably needs to be compromised or you have to limit what you can do,” he said.

Why the Shortage Persists  

Dr Nhlonzi traces the shortage to several interrelated factors. Training posts have not expanded in line with population growth, and not all trainees complete specialist programmes.

Experienced pathologists also leave the public system through retirement or migration to health systems outside South Africa that offer better resourcing, more predictable working conditions, and clearer career progression.

Simultaneously, the technical demands of pathology have increased. Molecular testing, genetic profiling, liquid-based cytology, and digital imaging now form part of routine cancer care, significantly increasing the time required per case.

South African laboratories are technically capable of offering many of these advanced tests.

However, Dr Nhlonzi suggests that the value of advanced diagnostics is ultimately limited by access to care;  “What’s the point of testing if there is no treatment available?”

Recruitment and Visibility  

Dr Nhlonzi also identifies limited awareness of pathology as a contributing factor to the workforce shortage. Many medical students and early trainees, he notes, are not fully exposed to the scope or impact of the discipline during their training.

Compensation and professional visibility also influence career decisions, particularly when skilled clinicians have opportunities in private practice or in health systems abroad.

The Promise and Limits of Digital Pathology  

Digital pathology and whole-slide imaging are often proposed as ways to address geographic gaps in specialist coverage. Several provinces currently have no resident pathologist, meaning samples must be transported long distances for review.

Dr Nhlonzi sees value in digital workflows that allow specimens to be processed locally and reviewed remotely by specialists in larger centres. Such approaches could reduce delays caused by transport and improve turnaround times.

However, he does not see technology as a substitute for specialist capacity. Without sufficient numbers of trained pathologists, backlogs and delays are likely to persist regardless of technological improvements.

Looking Ahead  

Despite the constraints, Dr Nhlonzi describes a strong commitment among pathologists working in South Africa’s public system. He believes that meaningful improvement will require expanded training capacity, better-supported learning environments, and a gradual movement towards sub-specialisation.

His own career, shaped by work across public and private sectors and a focus on diagnostic clarity in complex cases, reflects the broader challenges facing pathology in the country.

While technology may extend reach and efficiency, addressing diagnostic delays ultimately depends on long-term investment in people, training, mentorship, and the infrastructure that allows diagnostic expertise to reach every patient who depends on a timely diagnosis.