When Lungile, a hypothetical health-care user, waits for a blood test at a public hospital, she is not thinking about all the zeros in provincial budgets or intergovernmental disputes. She is thinking about her health. Like about 80% of people in South Africa, she places her trust in the public health-care system, the inner workings of which she will never see, and in laboratory professionals she will never meet. However, in using the system, she experiences its impact.
For her blood test, a nurse will draw the sample, seal the vial and send it to the closest National Health Laboratory Service (NHLS) facility. For patients, waiting for the results often feels uneasy. In addition to the immediate health concern, patients also find themselves in the hands of a system that needs to function well, not only on paper and in policy but also in the concrete reality of their particular case.
The NHLS plays a big role in public health in South Africa through epidemiology, surveillance and responding to public health outbreaks. Among other things, it is involved in HIV and TB programmes, conducting diagnostic tests for noncommunicable diseases and screening for cervical cancer. In essence, contemporary health care would grind to a halt without the robust laboratory infrastructure that the NHLS provides.
For patients, it means delayed diagnoses and disrupted care
Ballooning debt
At the end of May, parliament’s portfolio committee on health, which is tasked with overseeing the national department of health, met with representatives from the NHLS and the nine provincial health departments. The meeting revealed that outstanding debt to the NHLS had climbed to an imposing R11bn as of March this year. Most of this debt stemmed from KwaZulu-Natal, with around R3.94bn, and Gauteng, with roughly R3.3bn, both of which include debt from previous years.
This meeting confirmed what many in the public health system have warned about for years. This outstanding debt is not merely a matter of the numbers not adding up, is symptomatic of a serious failure in financial governance. Failing to pay or delaying payments for critical services rendered to the public health system also reflects poor co-ordination among government departments and entities.
The consequences of this can be dire.
Without these funds, the NHLS cannot sustain research, do proper disease surveillance, detect outbreaks or monitor antimicrobial resistance, or upgrade equipment. When a laboratory cannot replace ageing instruments on time, fill critical posts, modernise information technology or plan procurement with certainty, it is felt in hospitals and clinics.
For patients, it means delayed diagnoses and disrupted care, and those living in rural and underresourced communities often bear the brunt.
Time to act
Listening to presentations from the provincial health departments showed that this crisis can be prevented. There are provinces that are getting this right and paying their invoices to the NHLS within the required 30-day period. This shows that, even with budget constraints, laboratory services can be prioritised.
As chair of the portfolio committee, I have made it clear that it is now time to shift our oversight from concern to action that leads to actual consequences for those provinces that fail to pay their NHLS debts.
There had been instances in the past where the National Treasury intervened by withholding or redirecting funds when provinces failed to fulfil their responsibilities. The committee may need to engage the Treasury on ways to protect funding for laboratory services, including the possibility of direct transfers or ring-fenced funding where provinces fail to prioritise their obligations to the NHLS. The message is clear: we cannot allow a situation in which a province destabilises another public institution by failing to pay for services central to health-care provision.
We cannot just accept more vague commitments and assurances that the debt will be paid. Provinces with outstanding debt must provide clear repayment plans linked to strict timelines while continuing to pay current invoices within the required period. The committee will request quarterly progress reports on payments made to reduce the debt, as well as on actions taken against officials involved in this nonpayment.
We live in an era marked by emerging health threats and increasing demands on health services. It is therefore important to remind ourselves that health systems do not collapse overnight. They deteriorate gradually through deferred payments and normalised delays, among other things. By the time patients experience the full impact, the horse may have already bolted because we ignored the warning signs.
To be clear — this, here, is a serious warning sign.
Yet notwithstanding these pressures, laboratory professionals continue to demonstrate extraordinary commitment. Samples are being processed and results are verified. I commend these public servants who work beyond ordinary expectations to protect the service. However, we cannot bank on this devotion to become a permanent substitute for responsible governance.
The decision before us is whether we allow patients’ experience of the public health value chain between health facilities and NHLS laboratories to continue to be determined by delay and uncertainty, or by a public health system that understands the seriousness of its responsibilities and acts accordingly.
Patients like Lungile are placing their trust in the state. We must do better.
Muthambi is a member of the National Assembly and chair of the portfolio committee on health
This piece was published by Spotlight – health journalism in the public interest. Sign up for the Spotlight newsletter.
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