Grappling with huge staff shortages and shrinking budgets – like public healthcare facilities across the country – Gauteng's Health Department is further crippled by damning audit outcomes and legal lashings in the courts.
Opposition parties are calling for the resignation of MEC follwing the latest audit outcomes, announced this week, which Treasury warned that it was the only department in the province with non-compliant outcomes across every single audit area – due to a lack of effective internal controls.
The department's weak internal controls, irregular expenditure and mounting accruals drew sharp warnings from Treasury, reports City Press.
Critics argue that Treasury’s warning and the MEC’s defence emphasise a department that has long been at the centre of governance controversies, where progress on paper has yet to translate into improved service delivery.
Releasing the 2024/25 provincial audit outcomes, Gauteng Treasury & Economic Development MEC Lebogang Maile said that provincial departments collectively incurred R4.2bn in new irregular expenditure during the year, while 14 of 19 government entities achieved clean audits.
He added that while most departments posted improved audit performances, Health stood out as the only one flagged for non-compliance across all key areas.
The findings, based on the Auditor-General’s report, highlight systemic weaknesses in expenditure management, supply chain compliance and consequence management.
The department’s financial position also remains precarious. According to Treasury, only 37% of invoices were paid within 30 days during the 2024/25 financial year, compared with a provincial average of 97%.
The backlog of accruals, still exceeding R8bn, has left suppliers waiting for months. Some have withheld critical supplies, compounding shortages in hospitals and clinics.
Maile said the provincial government had begun engaging with the private health sector to help stabilise hospital operations, while insisting that Treasury support and stricter financial controls would help improve outcomes in the next audit cycle.
‘Not true’
Nkomo-Ralehoko has strongly rejected portrayals of her department as a “basket case” or “in ICU”, saying such narratives ignore the progress reflected in the AG’s findings.
“This portrayal does not accurately reflect the significant improvements reflected in the Auditor-General’s report,” she said in response to City Press questions.
Contrary to claims of stagnation, the department has “demonstrated tangible progress across key governance, financial management and internal control domains”, she insisted.
According to the MEC, one of the most significant achievements was big drop in the number of overall audit findings, down from 138 in 2023/24 to just 42 in 2024/25.
“This represents a more than 70% reduction, signalling a robust strengthening of control environments and effective oversight,” she said.
Further improvements:
- Medico-legal claims reduced from R16.2bn to R6.6bn, a decline of more than 50%;
Irregular expenditure down from R2.7bn to R1.5bn; - Finance-related audit findings reduced from 28 to seven, asset management findings from 34 to three; and
- Revenue and payroll findings eliminated entirely.
“By the end of July 2025, the department had achieved 82% compliance in settling valid invoices within the mandated 30-day period,” she said, adding that much of the backlog related to “legacy accruals under systematic resolution”.
These outcomes showed “progressive stabilisation” of financial discipline and a rebuilding of supplier trust, she claimed.
Still, the scale of its financial challenges remains daunting.
At the close of the 2024/25 financial year, accruals still stood at more than R8bn, effectively consuming 12% of the R67bn budget.
Opposition parties say this undermines the department’s ability to deliver services, forcing staff and equipment freezes while debt obligations are serviced.
Hundreds of unpaid companies are withholding vital supplies, staff are demoralised and essential equipment purchases are frozen.
Jack Bloom, the DA’s health spokesperson, described it as “an unacceptable situation that continues to cripple the system”.
These problems have also placed Gauteng Premier Panyaza Lesufi under pressure, with calls mounting for him to remove Nkomo-Ralehoko.
Bloom has called for both the MEC and her HoD, Lesiba Malotana, to be dismissed, citing the audit findings and a string of adverse court rulings.
Court rulings add to pressure
The department’s audit troubles are compounded by its legal lashings. Twice last year, the Gauteng High Court ruled against the department over its failure to address cancer treatment backlogs (see sidebar story).
Opposition parties seized on the rulings as evidence of leadership failure, urging the Premier to “make a decision about a failing MEC and a failing HoD who have now suffered two court defeats”, as cancer patients continue to die.
The MEC’s response leans heavily on reduced audit findings, improved financial controls and governance reforms. But the reality in Gauteng’s hospitals and clinics tells a different story.
Reports of overcrowded wards, broken equipment, stock-outs of essential medicines and long waiting times continue to plague facilities.
Service delivery protests have become more frequent, while unions warn that austerity measures linked to accrual repayments have worsened critical staff shortages.
The Gauteng situation is replicated across South Africca's state healthcare, reports the Sunday Times, with more than 25 000 critical staff vacancies, shrinking budgets and mounting debt, and with no relief or hopes of improvement in sight.
The number of patients treated annually in Gauteng’s public system has skyrocketed by 1m over the past three years. In the most recent financial year, provincial facilities recorded 19.6m patient visits – exceeding the total population of the province.
While the budget has remained static, the province’s Health Department continues to sink deeper into debt. This year, R8bn had to be cut from Gauteng’s R67bn Health budget before the financial year began. Nationally, these accruals stand at R24bn.
A Sunday Times investigation also revealed that KwaZulu-Natal and the Eastern Cape have the highest numbers of staff vacancies – about 7 000 each.
KwaZulu-Natal has seen 29m patients a year during the past two years. The Western Cape, with a population of less than 8m people, recorded 21m patient contacts (the province records patient “contacts” rather than individual patients treated).
Limpopo – population 6.4m – was third, with 14.9m patients seen last year.
Gauteng’s R67.1bn health budget for this year was a 3.6% increase on last year’s initial allocation of R64.8bn, later adjusted to R66.1bn, and way below the interest rate. The province’s population is more than 16m, but it also provides specialist treatment to patients from neighbouring provinces.
The National Department of Health (NDoH) confirmed that budget allocations for the public health sector had shrunk over the past few years because of austerity measures.
“The Health Ministry has been in discussions with the Finance Ministry for additional budget to enable the … system to respond to the challenges, including infrastructure upgrades such as refurbishing, constructing new facilities (and) recruiting additional health professionals,” spokesperson Foster Mohale said.
He added that they had pleaded for more funding, to appoint more doctors and to buy equipment. “This has resulted in (an) additional budget allocation from this current financial year.”
Reports from provincial Health Departments show financial constraints have hampered their ability to recruit professionals, including specialists – considered the backbone of the public health system.
Because of budget issues, Gauteng said it was unable to fill vacancies, beginning the past three financial years with accruals of between R6.8bn and R8bn, and with its budget being spent before the end of each year.
Spokesperson Motalatale Modiba said 19.6m patients were seen in the past financial year, up by 1m (from 18.6m) in 2022.
The highest spending over the past three years was on medical supplies – a total of R4.3bn, with R4.1bn and R4.3bn spent in the two preceding years.
Primary healthcare
Western Cape Health MEC Mireille Wenger said primary healthcare was the “main entry point, accounting for the majority of patient contacts each year”.
More than 19.1m patients were primary healthcare contacts in each of the past two years, up from 18.1m in 2022.
Wenger cited budget and policy constraints as some of the reasons they had not been able to fill their 3 070 vacant posts. “Staff attrition through retirement, resignation and relocation has until recently outpaced the ability to refill posts … in-year cuts to the budget, [after] negotiated wage agreements and subsequent austerity measures, required the department to reduce posts on its approved posts list,” she said.
KwaZulu-Natal, with the second-highest budget at R62.2bn, spent most of its allocated budget on the salaries of its 64 000 workers.
Medicine shortage
Spokesperson Ntokozo Maphisa said they faced “acute budget cuts”, which had limited resources and capacity over the years. In recent months, the department has also experienced medicine shortages across the province.
Human rights activist Mark Heywood said South Africans should not accept the poor quality of public healthcare service to which they were subjected (see also Talking Points). “We have a constitutional right of access to healthcare service … the reasons for poor service are to do with maladministration and corruption … if we could fix those things … it would be possible to improve quality,” he said.
Heywood said a decade of underfunding, with declining per capita spending, had led to a shortage of health staff. “The problem is … health is not treated as a political priority by the government, and it should be. The private healthcare system is also by no means perfect … it’s [overpriced] and there’s poor governance.”
But there was an urgent need to focus on both systems and improve health outcomes, he added. “We need … (a) shake-up of hospital boards so that they’re empowered to ensure quality of care … but they’re often staffed with cadres and people who are deployed despite not having knowledge of the system.”
The Free State said it estimated it had more than 7 000 vacancies. Spokesperson Mondli Mvambi said a review would help determine a revised number of posts required.
The Eastern Cape has almost 7 000 vacancies older than 90 days, due to budgetary constraints. The North West, which started the current financial year with accruals of more than R1bn, has 1 021 vacancies.
Mpumalanga has 873 vacancies, which include 142 clinical support staff, 126 enrolled nurses and 150 professional nurses.
“Attracting suitably qualified professionals to rural provinces remains a national challenge, particularly in regions without a local university with a dedicated health sciences faculty,” said Mpumalanga Health spokesperson Dumisani Malamule.
Limpopo has 1 965 vacancies, with almost 600 for staff and professional nurses. Though the total number of patients treated by the provincial health facilities has dropped from 15m to 14.9m, the province recorded accruals totalling R767m at the start of the financial year.
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Leaked SA govt analysis: Severe healthcare staff shortages by 2025
Chronic staff shortages add to growing mental healthcare burden
TB drug shortages hamper North West healthcare
Staff shortages and long waiting times plague KZN Health