The Gauteng Department of Health is facing a severe financial strain, with outstanding patient fees totaling approximately R4.6 billion. This debt has significantly impacted the department’s operations, including its ability to fill over 1,100 critical staff vacancies, repair medical equipment, and pay suppliers on time.
Chief Finance Director Siyabonga Jikwana, who also serves as the chief director for health economics, explained that the debt breaks down into two main categories. Of the total, around R1.8 billion is owed by other government departments, provincial administrations, and state entities. A major contributor to this intergovernmental debt is the Road Accident Fund, which owes more than R1.5 billion—a problem common across provinces where accident victims are initially treated in public facilities before potentially transferring to private care.
The remaining portion, approximately R2.6 billion (with figures citing R2.4 billion to R2.63 billion in related reports), stems from patient fees owed by self-paying individuals. Jikwana highlighted that a key reason for this accumulation is patients arriving at public hospitals without any form of identification, leaving the department with no legal recourse to pursue payments. Many of these patients come from neighboring countries, particularly Zimbabwe and Mozambique, and access care without providing traceable details.
Jikwana noted that the department previously lacked robust systems to identify patients at entry points, unlike banks’ Know Your Customer (KYC) processes that verify identity and financial status. He added that about 60% of this patient debt—largely attributed to foreign nationals—is considered irrecoverable, as these individuals often leave after treatment without follow-up options. This issue extends beyond the department’s control, involving border management processes.
Examples of the burden include high-volume facilities like Tembisa Hospital, where on average 1,400 babies are delivered monthly, and around 60% are from non-South African patients. These cases often involve late-stage presentations without prior antenatal care, making them more resource-intensive. Jikwana estimated the cost of a delivery at around R5,000 per day, with patients staying an average of seven days, resulting in substantial unplanned expenditure of roughly R40,000 per such case.
Self-paying South African patients are defined as those who can afford to contribute based on a means test, which assesses income and ability to pay. However, Jikwana acknowledged that the department has not always applied this robustly at entry points. Some patients claim no income or lack ID, while the department has a constitutional obligation to provide care regardless—unlike private facilities.
To address the crisis, the department has implemented interventions. It participates in the National Treasury-managed transversal contract RT27 of 2024, running from April 1, 2024, to March 31, 2029, for debt collection services. Since appointing five debt collectors around June 2025, the department has recovered approximately R28.8 million as of February 28, 2026, primarily from patient fees.
In the coming months, Jikwana said the department plans to deploy KYC-like solutions in most institutions. This will involve API integrations with Home Affairs for citizenship verification, SARS for income checks, and credit bureaus to combat falsified details and enable biometric identification—even if patients arrive without documents.
Jikwana emphasized the need for national government support to resolve broader challenges. These include border control measures, diplomatic engagements with embassies (noting that some from farther countries like Egypt and Morocco are more willing to pay, unlike bordering nations), and policies requiring upfront payments from foreigners. He highlighted ongoing engagements with the Road Accident Fund for current and historical debts, as well as political outreach to other provinces and entities.
The debt from other provinces arises when their residents use Gauteng’s specialized tertiary services, straining resources without corresponding budget allocations. Jikwana stressed that collective action across government departments and national levels is essential to alleviate the pressure and ensure sustainable quality healthcare delivery in the province.