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South African Journal of Bioethics and Law

versão On-line ISSN 1999-7639

SAJBL vol.15 no.3 Cape Town  2022 



How is South Africa going to implement NHI when corruption is so rampant?



As 2022 came to a close, it became patently clear that the fight against corruption in South Africa (SA) was no longer an uphill battle, but a mammoth crusade. The reality that corruption had become endemic and pervasive was overwhelming, tarnishing and even ruining the festive period for most people in the country. Despite SA having the third-largest economy in Africa and a strong history of activism, because of corruption it has been rated the most unequal country in the world.[1] Improper use of public resources for private ends has become progressively rampant since the dawn of our democracy, is a shameful reflection of the failure and betrayal of the ruling party, and has resulted in a huge trust deficit developing between the state and its citizens. Characterised by lack of transparency, weak accountability and inefficiency, corruption is a typical outcome of poor governance.[2]

State capture, political corruption whereby the state's decision-making processes are significantly influenced by private interests, was detailed explicitly by the Zondo Commission.[3] Between 2014 and 2017, it had already been estimated that state capture cost the country up to ZAR250 billion[4] and reduced the country's GDP (gross domestic product) growth rate by ~4% a year.[5] It has been stated that the damage caused by state capture during the Zuma administration impacted the country's economy so negatively that it effectively undid the efforts of the Mandela and Mbeki administrations in developing the economy.[6]

The effects of corruption have been catastrophic in all aspects of life for all in the country, except, of course, for the corrupt. Population health outcome is impacted negatively by this abuse of trust and intentional violation of duty.[2] This is particularly severe for the poor and disadvantaged. In SA, health facilities are exposed to corruption by the architecture of their governance. Hospitals in the state sector, most accounting bodies and regulators have chief executives who are political appointees. And this has been the situation for close on 30 years, with political nepotism, cadre deployment and patronage being the norm. For example, cliques are deployed by politicians so that human resources, procurement and licensing for facilities can be manipulated. With the current state of health services, it is evident that the wrong people are chosen for these executive jobs in the public sector. This patronage system with its illegal spending runs far too deep and costs the country billions of rands yearly. Irregular expenditure, i.e. contravening legal supply chain processes, is a strong indicator of corruption. During 2020/2021, the Gauteng Department of Health packed away ZAR3.8 billion in irregular expenditure. This was more than double the amount from the previous year. Rampant dishonesty prevails because the corrupt are protected from the consequences of their misconduct, and the honest, dedicated and committed are removed or threatened with removal.[7]

The current picture of the public healthcare system is that it is hanging by a very fine thread, and nearly ready to crash from its precarious breaking point. The lived reality of 50 million South Africans is that of standing in queues from 4 am with no guarantee of seeing a healthcare worker or even getting to the pharmacy before it closes. These long waits are often futile as a consequence of stock-outs and the lack of medical equipment because of unpaid bills and deliberate, unashamed theft within the facilities, and with networks on the outside.[8] Given the brazen corruption at the level of the power utility, Eskom has plunged the country into darkness with prolonged periods of loadshedding. Electricity and water outages are commonplace in our healthcare facilities.

There is little to no assistance from officials whose lexicon is devoid of care, caring and compassion. Corruption has flouted several Constitutional rights of people living in SA, including the right to healthcare. In the midst of this unbridled corruption, the very same corrupt government ironically pushes forward with its plans for universal health coverage (UHC) through the National Health Insurance (NHI). The goals of UHC, such that everyone needing healthcare can access quality services without financial hardship, and attain sustainable health outcomes, are laudable. This is something we must strive for, as it is a step in the right direction to attain justice in health for all. It is essential for health systems to be strengthened so that primary healthcare improves. But for this to be successful, government needs a reality check. Corruption must stop undermining our quest for equity, quality and responsiveness, and die the death it deserves. But will it? Is eradicating corruption a pipedream? And if so, will our long-awaited NHI be a pipedream too?

Ames Dhai




1. Pillay K. South Africa - a snapshot of its journey against corruption. Transparency International, 2022. (accessed 20 January 2023).

2. Naher N, Hoque R, Hassan MS, Balabanova D, Adams AM, Ahmed SM. The influence of corruption and governance in the delivery of frontline health care services in the public sector: A scoping review of current and future prospects in low and middle-income countries of south and south-east Asia. BMC Public Health 2020;20:880.

3. Phillip X. South Africa: 10 facts to know about the Zondo Commission reports. The Africa Report, 27 May 2022. (accessed 22 December 2022).

4. Citizen. R250bn lost to stae capture in the last three years, says Gordhan. The Citizen, 12 September 2017. (accessed 21 December 2022).

5. News24. Damage from state capture 'worse than suspected' - SARB. News24, 6 June 2019. (accessed 24 January 2023).

6. Mahlaka R. Years of Zuma. Current and ex-Treasury officials: State capture nearly destroyed South Africa. Daily Maverick, 31 January 2022. (accessed 10 December 2022).

7. Van den Heever A. How do you stop a hospital heist? Appoint a blunder-proof board. Daily Maverick, 17 August 2022. (accessed 20 December 2022).

8. Daily Maverick. NHI in times of collapsing public healthcare, rampant corruption and deep mistrust in government? Daily Maverick, 1 June 2022. (accessed 24 January 2023).

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