South Africa’s hospitals show 'uneven capability' as regulator warns compliance is not enough

Dr Lesiba Rashokeng, director: Certification and Enforcement, OHSC

South Africa’s health regulator – the Office of Health Standards Compliance (OHSC) – has conducted 4,487 inspections over seven years, revealing stark disparities in hospital performance – with 100% of quaternary hospitals compliant, but 19% of district hospitals rated unsatisfactory, meaning they fail to meet even minimum standards of care.

Presenting findings at the Hospital Show Conference hosted by Cohsasa and drawn from inspections, certifications and mandatory annual returns, Dr Lesiba Rashokeng of the OHSC said the data offers 'evidence, not anecdotes' about the state of healthcare quality – and points to a system where leadership, infrastructure and governance determine outcomes as much as clinical care.

The strongest performers are national (quaternary) hospitals – highly specialised referral centres where strong infrastructure and leadership correlate with consistent compliance. At the other end of the scale, district hospitals – the first point of care for most South Africans – are the weakest, exposing what Rashokeng described as a systemic imbalance in funding and resource allocation.

Of the district hospitals assessed, 37 facilities (19%) were graded unsatisfactory, raising concern because these facilities serve the majority of the population. Poor performance at this level drives patients upward in the system, placing pressure on regional and tertiary hospitals and increasing costs unnecessarily.

Across the system, 39% of public hospitals were rated 'excellent', showing 'pockets of excellence', while in the private sector only three out of 208 hospitals were non-compliant, two of them classified as unsatisfactory.

But Rashokeng stressed that compliance scores are only a snapshot in time. “A compliant hospital does not necessarily mean a high-performing or high-reliability hospital,” he said, warning against a culture of preparing for inspections rather than maintaining consistent standards.

The OHSC’s data identifies three core areas of failure:

• Leadership and governance
  
• Infrastructure and asset reliability
  
• Operational safety systems

Critically, failures are not confined to clinical spaces. “Hospitals do not only fail in wards or theatres – failure is also in executive boardrooms,” Rashokeng noted, highlighting that hospital CEOs and managers are among the most frequently failed areas. Acting appointments and leadership instability, particularly in rural facilities, were found to undermine sustained improvement.

The findings challenge the assumption that clinical expertise alone drives quality. According to Rashokeng, even the best surgeons cannot compensate for weak systems. Reliable infrastructure, functioning equipment, accurate data systems and effective communication of protocols are all foundational to patient safety.

He outlined a 'formula' for sustainable quality: clinical care + governance + infrastructure + data + patient-centredness. Missing any one element results in 'quality for show' rather than lasting improvement.

The OHSC is now pushing for a shift from reactive oversight – responding after incidents – to risk-based and eventually 'smart' oversight, including unannounced inspections, real-time data monitoring and routine self-assessment by facilities.

Hospitals are also being urged to adopt principles from high-reliability industries like aviation, where failure rates are as low as one in a million. In contrast, healthcare systems may fail as often as one in 100 activities, underscoring the need for a stronger focus on anticipating risk, investigating root causes and building resilient systems.

Rashokeng emphasised that quality must be driven from the top. Boards and executives should take direct responsibility, with accountability, stable leadership and sustained investment in infrastructure and maintenance.

He also called for urgent strengthening of district hospitals, warning that without functional entry-level care, the entire health system becomes strained.

The message from the regulator is blunt: compliance is only the baseline. “Sustained, patient-centred excellence is the mission,” Rashokeng said.