Maladministration, not foreigners, to blame for state of South African healthcare

Daily Maverick

14-07-2025

Although foreign nationals' treatment sparks debate, the key question is: what is a hospital bed's true cost in SA, and what structural weaknesses does this expose?
Recent demonstrations against foreign nationals at public healthcare facilities have intensified arguments that taxpayer-funded institutions, already overstretched, are being unfairly used.
Though these concerns are not entirely unfounded, as South Africa provides constitutionally protected healthcare to all inside its borders, the demonstrations reveal a deeper systemic issue in our public healthcare system.
South Africa's relative stability positions it as a migration destination for the citizens of many neighbouring countries, having a significant impact on border healthcare facilities. Combined with the legacy of apartheid-era health infrastructure, the attention given to foreign nationals often becomes a distraction from deeper systemic issues.
The reality is that healthcare infrastructure has persistently lagged behind demand and population growth, irrespective of nationality. Many border-area hospitals face heightened pressure, not primarily from migration, but rather from longstanding underinvestment in capacity and resources.
South Africa's healthcare expenditure
About 8% of South Africa's GDP is dedicated to healthcare, translating to about R10,000 per person annually. This expenditure includes both public and private healthcare sectors.
It's about one-tenth that of Organisation for Economic Co-operation and Development countries, but similar to regional neighbours such as Namibia, which spends about R8,000 per person.
However, raw spending figures mean little without outcome comparisons using metrics such as life expectancy, which in South Africa is slightly higher than in Namibia or Botswana. But Professor Alex van den Heever, chair in the field of social security systems administration and management studies at Wits University, says life expectancy is 'too broad as a metric'. 'Look at maternal mortality,' he suggested.
Maternal mortality statistics highlight healthcare governance and management shortcomings, suggesting that the primary issue is not hospitals being 'overrun' by foreign nationals.
Despite having a substantial public healthcare system, South Africa has one of the highest rates of private medical insurance globally, covering about 16% of the population, according to the Council for Medical Schemes. This starkly underscores disparities in healthcare access and spending in the country.
An average patient-day equivalent in a public hospital costs about R3,700 to R4,000, according to the National Treasury's 2023 Budget Review. This figure represents the total cost of providing care for one patient for one full day, encompassing all associated expenses such as staffing, medication and supplies. Notably, 64% of this cost goes to wages.
Van den Heever emphasises that despite significant wage increases since 2007, staffing levels have remained largely static, highlighting inefficiencies in resource allocation. Specific treatment costs underline this: a Caesarean section ranges from R18,000 to R22,000; tuberculosis treatment costs between R6,000 and R8,000; and antiretroviral treatment averages between R3,000 and R4,000 annually per patient.
The numbers paint a bleak picture of what is being spent per person annually, and they fail to demonstrate the human cost and distress caused to those denied access to care.
Janet*, a Zimbabwean who has been living in South Africa for more than a decade with a valid Zimbabwean Exemption Permit, described the challenges she faced. 'They [the hospital staff] said, 'Why are you here? Because you're a foreigner you must pay a certain amount – if you don't pay, they won't treat you'.'
The interaction occurred when Janet was seven months' pregnant and went to Rahima Moosa Mother and Child Hospital in Johannesburg for a routine checkup. 'They insulted me. They said I must pay because I'm a foreigner. They didn't want to check my ID or see my papers. They just said if I don't pay, I must go home,' Janet said, noting that many other people in her community – legally in South Africa from Zimbabwe – have faced similar challenges.
She stopped going to her appointments in the run-up to giving birth. 'They told me to pay R470 every week. I couldn't afford it, so I just stopped going.' She only returned when it was time to give birth.
A 2023 Health Ombud investigative report found that 40% of patients admitted at the Rahima Moosa Mother and Child Hospital were foreign nationals (although the investigation did not stipulate whether they were documented or undocumented).
Despite these significant numbers, there remains no mechanism for cross-border billing. The existing Southern African Development Community protocol addresses disease outbreaks, but it excludes routine healthcare services. 'No data system exists to raise an account […] The issue has drifted for 50 years,' Van den Heever confirmed.
Fixing the system
Despite severe criticism and resistance from some quarters, including over its costs and funding, the government is pressing ahead with the National Health Insurance (NHI) scheme.
The Department of Health's spokesperson, Foster Mohale, confirms that NHI implementation is in its initial phase, focused on foundational, institutional and organisational arrangements. 'The NHI implementation is going well with phase 1 (2023–2026) under way, establishing foundational structures including the NHI Fund,' Mohale said.
'Phase 1 provides for ministerial advisory committees focusing on healthcare benefits and health technology assessment, which should be complete by July 2025.'
Mohale said the department has also rolled out a supply chain management and payment checklist, pre- and post-audits, and a CFO forum to tighten procurement controls and reduce irregular spending.
The NHI alone might not bring the redress needed, but foreign nationals using South Africa's healthcare system is not the core challenge either. Hospital beds were already underfunded and overstretched long before border crossings increased.
The Auditor-General flagged about R1.8-billion as fruitless expenditure in the 2022/23 financial year, a sum significantly greater than any healthcare costs directly attributable to foreign nationals.
Van den Heever noted: 'It's cyclical – foreign nationals are the bogeyman every election.'
Structural inefficiencies mean longer wait times and diminished healthcare quality for the average South African patient. They wait longer for beds, or forever – but it's not because those beds are being occupied by others. The core issues lie in systemic inefficiencies, inadequate infrastructure investment and weak governance.
Effectively fixing South Africa's healthcare system means fixing its management and money first. Migration and foreign nationals are an easy target, especially during election season, but they're not the real reason people lie waiting for treatment in hospital corridors. Without real improvements in governance, finance and basic infrastructure, the promise stays a promise. DM
* Surname has been withheld.