South Africa’s Human Resources for Health (HRH) Strategy 2030 positions the health workforce as central to achieving Universal Health Coverage (UHC) and implementing National Health Insurance (NHI). Despite relatively high aggregate workforce densities compared to the African region, the country faced a projected shortfall of approximately 97,000 health workers by 2025 due to the spending trends. More critically, workforce distribution remains highly unequal across sectors, provinces and rural–urban areas. Implementation progress between 2019 and 2025 reflects a paradox: the Strategy is technically robust and well aligned with national and global frameworks (NDP 2030, SDG 3.c, NHI) yet systemically constrained in execution. Around 56,000 additional health workers had been recruited by 2023, but fiscal austerity, provincial hiring freezes and fragmented governance have limited sustained and equitable staffing gains, particularly in underserved areas. Major system constraints undermine implementation.