Provincial Health Departments are diverting funds for medical supplies, maintenance and other operating costs to meet medical claims payments, which collectively amounted to R1.57bn in the 2025/26 fiscal year, the Auditor-General has warned. At the same time, little progress was being made to address the failures that lead to harm, and officials are not being held accountable for implementing corrective measures.
Chris Bateman, for MedicalBrief, reports that Auditor-General Tsakani Maluleke’s latest assessment of provincial Health Departments paints a picture of systemic weaknesses that extend far beyond the courtroom: missing medical records, delayed responses to patient complaints, understaffed clinics, absent maintenance schedules, inadequate stock controls and senior management failures that too often go uncorrected.
South Africa’s public health system has also missed its own target for reducing medico-legal claims by R32bn. Provincial Health Departments paid R1.57bn to claimants in the 2025/26 fiscal year, yet their recorded medico-legal claims balance remained at R50.2bn by March 2026.
That balance is almost three times the sector’s target of reducing claims from R70bn to below R18bn by March 2024, set out in the 2019–2024 Medium-Term Strategic Framework.
The central message of Maluleke’s presentation to the South African Medical Legal Association’s annual conference on 8 October was that claims cannot be managed sustainably through legal and financial interventions alone. The failures that lead to harm must be addressed where healthcare is delivered, and officials must be held accountable for implementing corrective measures.
The recorded claims balance declined from R75.3bn in March 2023 to R63.3bn in March 2024, R58.2bn in March 2025 and R50.2bn in March 2026. But a declining balance does not, by itself, demonstrate that fewer patients are being harmed or that the underlying causes of claims have been resolved. Maluleke’s presentation distinguishes between the value of claims recorded against provincial departments and the payments made to claimants. The latter remained substantial: R4.6bn was paid across the nine provinces over three years.
In 2025/26 alone, the Eastern Cape paid R474m, Gauteng R456m and Northwest R230m. Together, these three provinces accounted for R1.16bn of the year’s R1.57bn in settlements.
These payments compete with other demands on already strained health budgets. The Auditor-General warns that departments divert money from medical supplies, maintenance, and other operating costs to meet claims obligations. The problem is compounded by limited budget provision for claims. Only a few departments made specific allocations for these payments, while others met them from their general budgets.
The Eastern Cape audit also recorded interest on late settlements as fruitless and wasteful expenditure and raised significant doubts about the province’s financial sustainability.
Three provinces carry 74% of the exposure
The distribution of claims points to the need for targeted intervention rather than a uniform response across all provinces. As of 31 March 2026, the Eastern Cape carried R18.6bn in claims, followed by Limpopo at R9.3bn and Gauteng at R9.1bn. Together, they accounted for 74% of the total. Mpumalanga recorded R6.1bn, KwaZulu-Natal R2.8bn, the Free State R2.1bn, Northwest R1.6bn, the Northern Cape R500m and the Western Cape R100m.
The Auditor-General’s wider concern, however, is that the same underlying problems recur across the sector: financial distress, leadership instability, inadequate internal controls, and insufficient accountability for service delivery. Nine of the 10 health departments audited had liabilities exceeding their assets, while accumulated unpaid bills across the sector exceeded R21bn.
Continued non-compliance with supply chain management requirements also compromises value for money and increases the risk of fraud.
Missing records
One of the most damaging findings concerns the basic documentation needed to establish what happened to a patient.
An audit of 27 healthcare facilities across all nine provinces found that 15 reported that medical records were missing or lost. At 17 facilities, records were not properly tracked after being issued, while 25 had inadequate record-storage conditions. Eighteen had too few staff responsible for records. In three of the nine paid claims reviewed, departments conceded because they could not find the medical record.
A missing record does not automatically establish negligence, but it can undermine a department’s ability to reconstruct events, assess a complaint fairly and defend its position in court.
The Auditor-General has examined medical-record management since 2017/18, including a dedicated audit of how institutions file, store, archive and dispose of records. The persistence of these weaknesses raises the question of why repeated audit findings have not translated into dependable record-management systems.
Staff shortages, manual paper-based systems, and the underuse of available information systems all contribute to the problem. But they do not remove management’s responsibility to ensure that records can be retrieved when patients, clinicians, investigators, or courts need them.
Weaknesses at clinic level
A separate 2022/23 audit of 27 primary healthcare clinics – three in each province – exposed weaknesses at the first point of contact for many public-sector patients. At 21 clinics, staff had not been appointed in line with requirements. Twenty-three had no maintenance schedule, while 24 had not determined the stock levels they needed.
Nationally, only 59% of primary healthcare facilities had achieved ideal-clinic status.
The audit identified slow recruitment, limited training, and inconsistent compliance with clinic protocols, alongside failures by managers to enforce improvement plans or hold staff accountable.
Leadership without consequences
Maluleke identified leadership instability, vacancies in senior positions and acting appointments at hospital level as factors weakening administrative oversight.
Governance structures at some facilities were absent, incomplete, or not functioning. At the same time, failures in financial management and irregular procurement rarely resulted in action against responsible officials, while senior managers delayed implementing plans to address internal and external audit findings. This is where the audit moves beyond documenting deficiencies to exposing a culture of weak accountability.
The Auditor-General’s framework envisages an accountability chain involving officials, senior management, accounting officers, executives, internal audit units, audit committees, provincial and national treasuries, legislatures, and other oversight institutions. Each has a responsibility to act on audit evidence.
The challenge is therefore not simply to identify weaknesses. It is to ensure that officials responsible for correcting them do so – and that oversight bodies can demonstrate whether promised improvements have materialised.
Legal reform cannot substitute for safer care
South Africa has pursued several initiatives to address medico-legal claims since the 2015 Medico-Legal Summit, which brought doctors, lawyers, and government together around patient safety, administration, and legal reform. But the Auditor-General’s position is clear: legal reform does not remove management’s responsibility for safe care, reliable records, and timely responses to patients.
The recommended corrective action is both operational and institutional – prevent avoidable harm, maintain dependable records, respond promptly to complaints, and ensure timely consequences for failures.
Health leaders must fill critical vacancies in records and claims functions, train staff, secure retrievable records, and act on non-compliance. Doctors and nurses must follow clinical guidelines, maintain clear notes, report incidents honestly and respond to patients respectfully. Lawyers and mediators must support fair assessment and appropriate resolution, while legislatures and treasuries must strengthen oversight and insist on adequate budget provision.
Note: The article references figures and findings from Maluleke’s 21-slide presentation. The figures describe different audit periods and populations: the claims balance is reported in March 2026, the facility complaints and records audit dates to 2021/22, and the primary healthcare clinic audit to 2022/23. Keeping those dates explicit avoids implying that all findings were collected in the same year.
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