Thirty-year-old mother of four, Ndanganine Mudau, has battled for more than a decade to obtain a birth certificate for her 12-year-old daughter, denying her access to a child support grant as the family battles to meet her growing needs.  According to the law, births should be registered within 30 days, but mothers who have faced bureaucratic hurdles can be locked out of access to services for their undocumented child.  Mudau says her daughter was born in Johannesburg in February 2014, but she says shortly after the birth she returned home to Tshikudini, in Musina Local Municipality.  In May 2014, she went to the Department of Home Affairs office in Musina to register her daughter’s birth. She says officials told her she first needed to return to Johannesburg to obtain the child’s birth confirmation record. “My child was born in Johannesburg, so the same year I travelled back to Johannesburg to get the birth confirmation record.” After obtaining the record in Johannesburg, Mudau says she returned to Musina Home Affairs. She says the department’s system was down and she was unable to complete the application. Officials told her to go home and wait for a call so that she would not have to travel back while the system was offline. Mudau says she never received the call. “Network is a challenge for everyone in Tshikudini. Sometimes we have to walk to a free wifi place provided by a spaza shop owner,” she said. In 2018, Mudau returned to Home Affairs in Musina. She says officials told her they had previously tried to contact her but could not reach her, and told her to return another time. After three attempts, Mudau says she could not afford another trip to Musina. “I really cannot do anything more than what I have done. The child is now in Grade 7, and I am not sure what will happen at matric level,” she said, as an ID document is required for learners to receive their qualifications. Health-e News has previously reported on undocumented people in rural Limpopo who struggle to access healthcare, social grants and other essential services.  There are no exact figures for unregistered births in South Africa, but late registration remains a problem. According to StatsSA’s latest available data, 76,000 births were registered late in 2024, accounting for almost 9% of all birth registrations that year.  Missing out on social support Mudau has four children, three of whom have birth certificates. She survives on social grants but receives a grant for only three of her children. “Lack of a child support grant is a very serious problem because my child is growing, she needs more things that I am struggling to provide,” says Mudau.  According to the Cape Town-based Scalabrini Centre, birth registration is far more than an administrative process. It provides legal recognition of a child’s existence and an essential gateway to fundamental rights and services, including healthcare, education and social support.  For parents like Mudau, late registration adds a number of additional bureaucratic hurdles, including additional supporting documents and a screening interview.  For more information on the full late registration process, click here. Distance adds another barrier For residents of Tshikudini, the distance to the Home Affairs offices adds another challenge. Musina is about 60km from Tshikudini. Residents say public transport is available, but the journey costs about R110. For unemployed families like Mudau’s, who may need to make several trips to complete a birth registration process, the cost for public transport is unaffordable. Community leaders say Mudau is not an isolated case. “It is difficult to come up with the numbers of people who do not have birth certificates because such residents do not avail themselves,” says Didzhana Zacharia, one of the community leaders. According to Lucas Manebaneba, chairperson of the Tshikhudini Concern Group, the Department of Home Affairs has never provided mobile services in the area. “Home Affairs has never visited our area, but only neighbouring villages such as Folovhodwe and Madimbo,” says Manebaneba. Health-e News reached out to the Department of Home Affairs about Mudau’s case and what she needs to do to register her daughter’s birth, but had not received a response by the time of publication.  Author Bernard Chiguvare Bernard Chiguvare is a Zimbabwean-born freelance journalist based in Limpopo with more than a decade of experience. He focuses on health, social justice and issues affecting communities. His work has appeared in local and international publications. View all posts

Thirty-year-old Sthembile Mkhize from KwaNyuswa in KwaZulu-Natal says she is afraid to return to her local clinic after she was told to leave the facility during the night while waiting for an ambulance to take her to hospital.  Mkhize says she arrived at the 24-hour Halley Stott Clinic with her boyfriend at around 3pm on 10 September after experiencing abdominal pain, vomiting, diarrhoea and severe weakness. Mkhize says she was taken to the high care unit where healthcare workers placed her on a drip and inserted a urinary catheter. She says nurses informed her that an ambulance had been called to transfer her to St Mary’s Hospital.  Mkhize and her boyfriend, Nkululeko, say they waited for several hours but the ambulance did not arrive. At about 8pm Mkhize says she told the night-shift nurse that she was tired of waiting and the nurse asked her to wait until 10pm.  According to Mkhize the ambulance had still not arrived by 1am.  She says after repeatedly asking how much longer they would have to wait for the ambulance, the same nurse asked her to sign a form. Her catheter was then removed and she was told to leave the health facility.  Mkhize says she did not have enough time to read the document and was not given a copy. She believes she was asked to sign a release form stating that she had refused treatment.  Mkhize and Nkululeko say they spent the rest of the night outside the clinic waiting for daylight before they were able to take a taxi home.  Afraid to return Mkhize posted about the experience on social media shortly after being asked to leave the clinic. She says clinic management contacted her the following day to apologise for the incident.  According to Mkhize, management told her there were not enough ambulances in the area and that the nurse should not have told her to leave the clinic. Health-e News has not independently confirmed what was signed during her treatment at Halley Stott Clinic. Following the phone call, Mkhize returned to the clinic on the same day. An ambulance was called again, and this time it arrived and transferred her to St Mary’s Hospital for follow-up care.  According to Mkhize she was diagnosed with an intestinal parasite, received treatment and was discharged from St Mary’s Hospital later that night.  Mkhize says she has been told to return to Halley Stott Clinic on 14 November for further follow-up care, but she is now afraid to return and says she would prefer to get follow-up care from a different clinic.  “I am afraid to go back, what I have experienced that day has left me afraid to seek healthcare at my clinic,” she says. “Even after I was called by the management I could see that the staff and some healthcare workers who knew about my story were talking behind my back.” “How can I go back there again?” “I am afraid of my local clinic and I don’t want anything to do with it,” she says. According to Mkhize, management at Halley Stott Clinic promised to assist her with a referral letter for follow-up care at another facility, but nothing has happened since.  Ambulance shortages under scrutiny Mkhize’s experience comes amid ongoing concerns about ambulance shortages and response times in KwaZulu-Natal.  Last month the provincial legislature conducted oversight visits to EMS bases across the province. Preliminary findings from the visits showed that ambulance and staff shortages and slow response times remained concerns. As of 21 May, only 248 of the province’s 448 ambulances were operational. In March, the KwaZulu-Natal Legislature’s Standing Committee on Public Accounts (SCOPA) identified an acute lack of ambulances. The committee said chronic delays in repairing state vehicles were contributing to the challenges faced by the province’s emergency services fleet management.  KZN Department of Health Health-e News sent questions to the KwaZulu-Natal Department of Health twice last month. The department did not respond to our queries, but Mkhize says she and Nkululeko were contacted on 25 September and asked to attend a meeting at the clinic.  Mkhize says when they said they could not afford transport, they were told someone would collect them the following day, but nobody arrived and she has received no further communication. Mkhize says she wants to know what measures the hospital will take to prevent this from happening to other patients in the future.  “I know I am not the only one who has been treated like this in this clinic.”  The department had also not responded to Health-e News’ follow-up questions by the time of publication.  Author Sandile Mbili Sandile Mbili is an award-winning freelance health journalist and radio drama scriptwriter based in KwaZulu-Natal. He has contributed to Health-e News since 2016 and is an Africa Health Communications Fellowship fellow through Fraycollege. He has written and produced more than 10 radio dramas and won two MTN Radio Awards. View all posts

South Africa’s medical-negligence crisis is exposing failures far beyond individual doctors and nurses, with experts warning that weak leadership, poor adherence to clinical guidelines, inadequate documentation, staff shortages, and a lack of reliable data are allowing preventable harm to remain invisible. The warning comes as the Eastern Cape reports that its estimated medico-legal liability has almost halved, from R38 billion to just under R19 billion over five years. But experts caution that a lower projected compensation bill does not necessarily mean fewer patients are being harmed. Former Health Ombud Professor Malegapuru William Makgoba says South Africa still lacks a reliable national picture of how many patients die or suffer serious harm because of failures in healthcare. “We still have no idea what the contribution of the medical profession is to mortality.” Professor Alex van den Heever, chair of Social Security Systems Administration and Management Studies and an adjunct professor at the Wits School of Governance, says the country’s estimated medical-negligence liability should be treated as a warning about healthcare delivery rather than simply a financial problem. “The legal process is the consequence of the failure to prevent negligence,” he says. The concerns come ahead of the South African Medical Legal Association’s (SAMLA) annual conference in Gauteng, where experts will discuss medico-legal risk, patient safety and accountability in healthcare. Billions in potential liability National Treasury puts provincial medico-legal contingent liabilities at R57.6 billion for 2024/25, down from R62.5 billion the previous year. The figures represent potential future obligations rather than money already paid. Actual provincial settlements average about R1.5 billion annually. The Eastern Cape has sought to reduce its exposure partly by providing some injured patients with future care in public facilities instead of paying large lump sums for anticipated medical and rehabilitation costs. But that approach depends on the state’s ability to provide the promised care over the patient’s lifetime. A Supreme Court of Appeal judgment on February 11, 2026, highlighted the risk. The court overturned an Eastern Cape High Court order substituting public healthcare and undertakings to pay for lump-sum compensation for a child injured through negligence. The province had conceded liability. The appeal court found that the evidence did not justify confidence that lifelong treatment and future payments would reliably be provided. The scale of medico-legal claims has also prompted government intervention. The South African Law Reform Commission’s investigation into medico-legal claims was initiated following requests from the Department of Health and the Minister of Justice and Correctional Services, amid concern about escalating medical-negligence claims and their financial impact on the public health sector. The commission released its final report and proposed legislation on 29 September. Warning signs in maternity care Eastern Cape midwife and nurse educator Dr Luleka Gcawu’s research shows how failures at ward level can become medico-legal cases.   A woman with abnormal blood pressure may be assessed but the required intervention does not follow. An abnormal foetal heart rate may fail to trigger the prescribed response. Monitoring may occur less frequently than guidelines require, or observations may be made without being recorded. “Sometimes the woman’s BP is checked as per guidelines – but not documented,” Gcawu says. She says training alone does not guarantee compliance. Some healthcare workers fail to implement updated guidelines despite having received training. Her research identified behavioural factors including poor patient relationships and failure to respond appropriately to identified problems, alongside system pressures. She also points to shortages of nurses, midwives and trainers, inadequate resources, high patient-to-nurse ratios, difficulty securing ambulances and unstable leadership. “Sometimes training is scheduled, but midwives are not released to attend. They need to look after patients. And there are not enough trainers,” she says. Her research found that behavioural and system-failure factors could account for more than half of the factors contributing to litigation. Gcawu says maternal healthcare illustrates the consequences.  National Department of Health data put South Africa’s institutional maternal mortality ratio at 105.2 deaths per 100,000 live births in 2023. The Western Cape recorded 71.8, while the other provinces ranged from about 101.5 to 166.6. Neither every adverse maternity outcome nor every cerebral palsy case represents negligence. But failures to recognise and respond to complications during childbirth can result in preventable injury and substantial medico-legal claims. For health authorities, the recurring question is whether systems are identifying these failures and changing practice. Who is accountable? Makgoba and Van den Heever both argue that accountability cannot stop with individual clinicians. Makgoba points to the Life Esidimeni tragedy as an example of how leadership and management failures can have catastrophic consequences. “Care is central” “You can’t have a system of caring that’s devoid of good interpersonal or inter-institutional relationships,” says Van den Heever. He says hospital managers need both responsibility and the authority to enforce standards. “You have to have a captain of the ship.” Van den Heever identifies leadership instability, political interference, fragmented workforce planning and weak management structures as factors that can undermine accountability. Gcawu independently raises concerns about instability among senior managers, including the prevalence of acting appointments, and says system failures can compound individual shortcomings. The issue is therefore not simply whether a nurse, doctor or midwife made a mistake. It is whether the institution had the staffing, supervision, leadership and systems required to prevent, identify, and correct the mistake. SA cannot fix what it cannot measure Makgoba’s concern extends to the absence of reliable national data on medical error. Medical error is not routinely recorded as a standalone cause in national mortality statistics. Healthcare failures can therefore remain hidden within broader categories of disease or injury. Makgoba says errors have traditionally been managed through internal processes such as morbidity-and-mortality meetings, pathology reviews, and management procedures. “If you know what percentage of deaths are from medical errors, then you can plan and educate your doctors properly.” Without reliable information, policymakers cannot accurately assess the scale of the problem, educators cannot target training effectively and managers cannot establish whether interventions are working. The same information gap affects the private sector. Van den

In April 2023, the National Department of Health published Draft Regulation R3337, proposing changes to the way foodstuffs are labelled and advertised in South Africa, including the introduction of prominent front-of-pack warning labels on certain products high in sugar, sodium and saturated fat. More than three years later, South Africans are still waiting for these regulations to reach the finish line. Three years is a considerable period in public policy, particularly when the policy in question concerns a preventable contributor to the country’s growing burden of non-communicable disease. During this time, the evidence supporting clearer food labelling has continued to grow internationally, while South Africa’s proposed regulations have remained caught in a lengthy process of consultation and negotiation. The country now needs to move from deliberation to implementation. We have been debating this for long enough The case for front-of-pack warning labels did not begin with the publication of R3337. South African researchers have spent years examining how consumers understand nutrition information, which warning-label designs are most effective and how such measures could work within the South African food environment. The proposed system has therefore emerged from a substantial body of local research, public consultation and policy development rather than being an intervention introduced without consideration of its potential consequences. There is also considerable international experience to draw upon. Countries including Chile, Mexico and Argentina have introduced front-of-pack warning labels, while the World Health Organization has recognised interpretive front-of-pack labelling as an important policy measure for helping consumers identify products with excessive amounts of nutrients of concern. Evidence from countries that have implemented these systems indicates that warning labels can improve consumers’ understanding of the nutritional quality of products and can create incentives for manufacturers to reformulate products to avoid receiving warnings. South Africa should continue to consider legitimate questions about how the regulations will operate in practice. However, after years of research, consultation and policy development, the central issue should now be how the regulations can be implemented effectively rather than whether the country should continue debating the principle of clearer food labelling. NEDLAC must help decisions move forward This is where the current process involving the National Economic Development and Labour Council (NEDLAC) becomes particularly important. NEDLAC has an important constitutional and institutional role in South Africa’s system of social dialogue, bringing together government, organised business, organised labour and community constituencies to consider policies with significant socio-economic implications. Meaningful engagement with affected stakeholders is an important part of good policymaking, particularly where regulation may have economic and commercial consequences. However, consultation is ultimately intended to improve decision-making. It should not become a mechanism through which decisions are indefinitely postponed. NEDLAC’s own protocol for the tabling of matters recognises the importance of concluding its processes within a reasonable period. The protocol indicates that, unless a matter is exceptionally complex, the NEDLAC process should ordinarily be completed within six months. This does not mean that complex policy questions can or should be rushed. It does, however, establish an important principle, in that social dialogue should have a reasonable endpoint. R3337 has already been under consideration for substantially longer than that period since its publication in 2023. If the regulations are now before NEDLAC, this process should be used to address outstanding issues and enable government to make a final decision. It should not become another stage at which an already lengthy policy process is allowed to drift without resolution. Delay has consequences for public health The consequences of delay should also be considered in the context of South Africa’s health burden. The country faces high levels of obesity, hypertension, diabetes and other non-communicable diseases, with unhealthy diets contributing to this burden. Government therefore has a legitimate public health interest in creating a food environment in which consumers can more easily understand the products available to them and in which manufacturers have incentives to improve the nutritional quality of those products. Front-of-pack warning labels are not a solution to every problem within the food system, and they should not be presented as one. They are, however, one evidence-based measure within a broader package of interventions aimed at improving diets and reducing exposure to unhealthy food environments. The argument that consumers can simply consult the existing nutrition information on the back of a package also overlooks the purpose of interpretive labelling. Consumers make purchasing decisions quickly, often while navigating a large number of products and competing marketing messages. Nutrition information that requires considerable time or nutritional knowledge to interpret does not provide the same form of information as a clear warning displayed prominently on the front of a package. Public policy has a role in ensuring that important information is accessible at the point where decisions are made. Government must now make a decision The responsibility for bringing R3337 through its final stages ultimately rests with government. Legitimate concerns raised by business and other stakeholders should be considered, but consultation must ultimately lead to a decision. After three years of research, public engagement and policy deliberation, South Africans should not be left waiting indefinitely while the regulations move through one procedural stage after another. A public countdown is now calling on the Minister of Health to approve R3337 by 10 December 2026. This deadline provides a clear opportunity for government to demonstrate that evidence-based public health policy can move from consultation to implementation. NEDLAC has an important role in facilitating social dialogue, but it should not become a place where health resolutions go to die. South Africans have waited three years for stronger protection from an unhealthy food environment. The evidence has been considered. The stakeholders have been heard. Now government must act. Authors Zukiswa Zimela Zukiswa Zimela is Communications Manager at the Healthy Living Alliance (HEALA), a coalition of civil society organisations advocating for equitable access to affordable, nutritious food in South Africa. View all posts https://heala.org/ Communications Manager Darshen Naidoo Darshen Naidoo is a Public Health Law and Policy researcher at PRICELESS SA at the South African Medical Research