Auditor-General exposes South Africa's public health system on the verge of collapse

IN a scathing and alarming briefing to Parliament’s Select Committee on Social Services on October 29, the Auditor-General of South Africa (AGSA) laid bare a public health system in freefall — plagued by financial ruin, institutional rot, and a near-total absence of accountability.

The evidence, drawn from AGSA’s 2024/25 audit of the Department of Health, paints a picture not of mismanagement, but of systemic betrayal — one that is costing patients their lives. From hospitals without operating theatres for 28 years to R24 billion in unpaid bills, from vandalised TB facilities to provinces still using paper “flash books” to track invoices in 2025, the report confirms what many have long suspected: South Africa’s public health system is being cannibalised from within.

When reached for comment, Foster Mohale, director of media relations at the Health Department, said the public health sector had faced long-term financial strain. “The public health sector has suffered consistent underfunding across all provinces for many years.”

Mohale said a brief boost that was seen during the pandemic had faded. “There was a brief improvement in the response to Covid-19, but this has not been sustained.” He further said that wage agreements had not been matched by budget increases. “Part of the problem has been the annual agreements on improvements to conditions of employment, which have not been supported by the additional funds required for salaries, benefits and overtime.”

The financial state of the sector is nothing short of catastrophic, as the AGSA told the Committee: “Nine out of 10 departments have liabilities exceeding assets… R24bn in unpaid accruals rolling over to the next year.”

These are not abstract fiscal figures; they represent medicine not delivered, nurses not paid, and surgeries cancelled. According to the AGSA, in Gauteng alone, R5bn to R8bn in accruals are carried forward annually, meaning the province begins each new financial year with a significant chunk of its budget already spent.

AGSA, Gauteng auditor Mariette Hefer said: “In 2024, the payouts were nearly R700 million against a R179m budget. For 2024–2025, the department budgeted R119m but has already paid out R428m.” This chronic under-budgeting of medico-legal claims — a known, recurring liability — diverts funds from primary healthcare.

The DA’s Nicola Du Plessis said: “The high costs of medico-legal claims reflected a system that was fundamentally broken… this issue was particularly alarming as it affected primary healthcare, the foundation of the nation’s wellbeing.”

Mohale said medico-legal summonses did not equal final state liability. “It is important to indicate that the amounts claimed for medico-legal as reflected in the summons are not necessarily the amounts that the State will have to pay.” He emphasised the legal burden of proof. “The Plaintiffs must still prove the damages suffered and whether they have been caused solely by the negligence of the health practitioners.”

Mohale further said that courts often awarded less than claimed and that fraud was also a factor. “In some instances, the courts award damages substantially lower than what the Plaintiffs have claimed. Other claims are fraudulent, as indicated in the Preliminary Report of the SIU in 2024. This makes it very difficult to budget for these claims.”

He said the volume and timing of claims were unpredictable. “The Department cannot anticipate the number of medico-legal claims that can be submitted in a financial year and the monetary value thereof. Furthermore, the Department would not know how many claims will be finalised by the Courts within such a financial year.”

In KwaZulu-Natal (KZN), a brief reprieve came in 2022 when a permanent chief financial officer (CFO) was appointed, leading to a clean audit. But by 2024/25, the department regressed again. AGSA, KZN auditor Erin Sampson said: “The previous head of department’s (HOD’s) term ended earlier in the year, and an acting HOD was appointed in February 2025. Other key positions, including the chief information officer (CIO) and chief audit executive (CAE), were filled by acting officials, resulting in divided responsibilities, weak accountability, and poor follow-through.”

The result? A culture of non-compliance. Sampson said: “Consequence management was severely lacking, contributing to a pervasive culture of non-compliance within the department.” Nationally, 90% of health departments showed material non-compliance with legislation, and almost no disciplinary action followed.

At the heart of the collapse is a leadership vacuum so profound it defies belief. AGSA, North West Auditor Marcus Mooketsa said: “The CFO position had been vacant for at least three years… the chief director… had been acting as the CFO, leaving their original position unfilled.”

Meanwhile, the Eastern Cape faces R22bn in total liabilities, according to AGSA, with R7bn in accruals. AGSA, Eastern Cape auditor Siphokazi Makubalo said: “The Department has been forced to reprioritise existing funds when courts enforce payments… new controls have since been implemented to prevent similar occurrences.”

Mohale specified the total and current-year amounts. “The budget speech announced R20.773 billion for the three years, with R6.7bn allocated for this financial year.” He pointed out that disbursement to provinces was delayed. “This money has finally been allocated to provinces more than six months into the financial year.”

Mohale said the National Health Council had planned how to use new funds effectively. “The National Health Council (NHC), also known as the Meeting of Ministers and Provincial MECs for Health (MinMEC), has been working on how to create a meaningful impact when additional funds are available.”

Patient safety is not just compromised; it is ignored. AGSA told the Select Committee that one Free State hospital had lacked an operating theatre for 28 years. Oversight visits confirmed the horror. The EFF’s Meisie Kennedy said: “Health institutions are meant to be places of healing, hygiene, and safety, yet the reality reflected in the report shows otherwise… the absence of adequate maintenance schedules, the presence of safety hazards, and the deplorable conditions.”

Out of the 21 health facilities that AGSA audited, six had no maintenance plans at all. AGSA infrastructure specialist Nancy Mthethoa said: “The six hospitals without maintenance plans were located in the Eastern Cape, KZN, Mpumalanga, and Northern Cape.”

Mohale stressed that healthcare demand and continuous operations intensified the pressure. “This is acute in health because services continue 24 hours a day, 365 days a year, the population continues to grow, and demands for healthcare are rising.”

Mohale said the department had pushed decision-makers for relief. “We have lobbied the National Treasury, the Cabinet and Parliament to improve the situation.” He added that funding was announced for the medium term. “The Minister of Finance announced an additional funding allocation for the health sector for the 2025/26 financial year and the medium-term expenditure period.”

No single case better symbolises the waste than the Manzupa TB facility in the Free State, which was vandalised and abandoned. AGSA, Free State auditor Gregory Coetzee said: “The entire facility had been repurposed in 2019 to cater for extreme TB patients… [but] was later vandalised, resulting in significant financial and operational losses.”

AGSA issued a material irregularity, a formal finding of serious misconduct causing financial loss, and criminal cases were opened. Disciplinary action was taken against the security manager. Coetzee, however, revealed: “At present, there is no individual identified for financial recovery.” The EFF’s Asanda Matshobeni said: “The cost of the equipment involved amounted to R29m, a significant expenditure that had yielded no benefit to patients.”

While the world digitises healthcare, North West clings to paper. Mooketsa said: “The Department relies on hard-copy record books, referred to as ‘flash books’, to record the dates invoices are received, paid, or remain outstanding… highly prone to errors, inefficiencies, and breakdowns.”

National digital health systems exist, but are ignored. AGSA told the Select Committee that: “National digital health systems remain poorly implemented, with weak governance and reliance on manual, error-prone processes.” Even the rollout of the Health Patient Registration System (HPRS) is incomplete, with AGSA promising to submit a list of non-compliant provinces in writing.

Mohale said provinces would drive the effort to lower unpaid bills and urged efficiency measures, including digital systems, to cut duplication. “Furthermore, the provincial departments are encouraged to implement efficiency measures to reduce the cost of providing health services. The introduction of HPRS and patient electronic systems will prevent the hopping of patients from one facility to another and the associated costs.”

Amid the despair, only the Western Cape bucked the trend.

The ANC’s Makhi Feni asked AGSA to explain what practices made the Western Cape successful in maintaining clean audits and how those governance models could be replicated. AGSA deputy business unit leader Nelisiwe Mhlongo said: “Provinces achieving clean audits typically have strong, institutionalised internal controls and effective governance processes. These include consistent reviews, active leadership involvement, and timely corrective actions.” The implication is clear: Failure is not inevitable. It is a choice.

The human cost is immeasurable, but the committee members did not mince their words. The DA’s Jeanne Adriaanse said: “The Department of Health was ‘bleeding money’ at the expense of patients… poor patient record management and chronic staff shortages… overworked healthcare workers and unfilled vacancies [are linked] to an increase in medical-legal claims.” The MKP’s Lungile Mhlongo said: “Ongoing non-compliance disproportionately affects rural areas, where communities already face limited access to healthcare, thereby compromising the life expectancy and wellbeing of the most vulnerable citizens.”

Even AGSA — usually restrained, technical, and bureaucratic — sounded desperate. AGSA business unit leader Thabelo Musisinyani said: “Many recommendations remain unaddressed simply because they are not followed up on during the year, leading to repetition of the same issues in subsequent audits… I encourage the committee to keep ‘a finger on the pulse’ through more frequent oversight engagements.” She proposed quarterly tracking of audit recommendations, a radical but necessary step.

Committee chairperson Desery Fienies agreed: “The committee would take the overall recommendation seriously and would ensure that quarterly tracking and follow-up on the AGSA’s recommendations become part of the committee’s regular oversight process.”

Mohale said to this end, a process commenced at a workshop held in November 2024 and subsequent meetings that culminated in four agreed health sector priorities that were adopted during the NHC meeting held on the 10th and 11th of April 2025, namely:

• “Appointment of health professionals (1200 medical doctors, 200 nurses and 250 other health professionals across the country).”
• “Implementation of the court order on the appointment of Community Health Workers (CHWs), which will bring over 27000 CHWs into full-time employment.”
• “Procurement of hospital beds, linen and mattresses. It should be noted 1.4 million items that were identified by hospital managers are to be procured, including specified linen items to be procured from Supported Employment Enterprises (SEE) of the Department of Employment and Labour.”
• “Reduction of accruals within the health sector, focused on oxygen, medical equipment, National Health Laboratory Services (NHLS), South African National Blood Services (SANBS) blood products, and medicines.”

Section 27 of the South African Constitution guarantees everyone the right to healthcare. But when a hospital has no operating theatre for 28 years, when R29 million vanishes into a vandalised TB clinic, when acting officials run billion-rand departments, and when patients die because medico-legal claims steal from primary care, that right is a mirage. The AGSA report is not just an audit. It is a forensic indictment written in the state’s own hand.

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