How primary healthcare provision is split between SA’s 3 spheres of government

On a cold morning in October 2025, members of Operation Dudula descended on the pink gates of Yeoville Clinic in the Johannesburg inner city.

It was not their first time there, but the mission was the same: preventing foreign nationals from entering.

Speaking to eNCA, a prominent leader of Operation Dudula, Simphiwe Shabangu, said they believe that people who have migrated from other countries must use private health insurance rather than the public health system.

At the gate, tension built as people arrived to seek care. Some were stopped, others argued for entry, while journalists documented the confrontation unfolding outside the clinic.

A grey-haired man in a white cap pushed his way to the media covering the chaos and asked: “They don’t allow anyone inside… Where is the lady in charge of the clinic? What does she have to say about this?”

The question extends far beyond that one moment at Yeoville Clinic.

It goes to the core of how public healthcare is governed across South Africa. Section 27 of the Constitution guarantees everyone the right to have access to healthcare services. But when that access is disrupted or blocked, who is responsible for restoring it?

As the local government elections draw closer, this is a question relevant to all voters. From a patient’s perspective, responsibility may sit with clinic management, municipal authorities, provincial health departments and national government – either individually or together.

But how responsibilities are shared – and who ultimately answers when access to care is disrupted – is not always clear.

The three spheres of government

Health services are delivered across three spheres of government: national, provincial and local. While each sphere is autonomous, they must work together to ensure access to healthcare services. This is known as cooperative governance.

“Schedule 4 Part A of the Constitution lists health services as a concurrent function, meaning that both national and provincial governments exercise authority over it,” said Professor Jaap de Visser, South African research chair in multilevel government, law and development at the Dullah Omar Institute.

However, they operate on different levels.

The national government is responsible for ensuring the constitutional right of access to healthcare services. This mandate is set out in the Constitution and the National Health Act (NHA), which assign the National Department of Health the role of developing policy and coordinating the health system.

According to section 25 of the NHA, the implementation of health services takes place at provincial level, where departments manage hospitals, clinics and health personnel. This includes responsibility for primary healthcare services such as school health, maternal and child health and the treatment of long-term conditions including HIV and diabetes.

As De Visser explained, “the national department doesn’t run hospitals – it is run by the provincial department of health”.

Local government plays a different but important role. Municipalities are responsible for what is called municipal health services (essentially environmental health services), De Visser said, which focus on preventing illness before people reach clinics or hospitals. “This includes monitoring the safety of drinking water, ensuring that waste is collected and disposed of safely and inspecting food outlets for hygiene and safety.”

Ensuring clean air also falls under this general local government mandate to ensure a healthy environment. (Spotlight will zoom into what this environmental health function entails in an upcoming article.)

But in reality, the lines are not always this neat. In some metropolitan municipalities, such as the City of Cape Town and the large Gauteng metros, local government also plays a role in delivering primary healthcare services. Primary healthcare services are never run by district or local municipalities, only by some metropolitan municipalities.

Adapting healthcare to local needs

“Where a metro runs these (primary healthcare) services, it is always done on an agency basis for the province,” explained Professor Alex van den Heever, chair of social security systems administration and management studies at the University of the Witwatersrand. Essentially, while provinces are responsible for providing primary healthcare services, they are authorised to delegate the related functions to capable metros.

For example, the Gauteng Department of Health has a section 156(4) constitutional arrangement with the City of Johannesburg to provide primary healthcare services. This is known as a service-level agreement (SLAs).

SLAs operate within South Africa’s district health system, Van den Heever says, introduced through the NHA in 2005 to address the fragmented and unequal health services inherited from apartheid.

The system divides the country into 52 health districts aligned with municipal boundaries, designed to enable planning and delivery of healthcare services that respond to local conditions.

In principle, this structure allows districts to adapt services to local needs rather than applying a uniform national model. In practice, it also means that the delivery of healthcare is shaped through negotiated arrangements between different spheres of government.

It is at the level of service delivery that these arrangements become most visible, as governance structures are translated into the daily functioning of clinics.

How clinic functions are divided in Johannesburg clinics

One such SLA is between the City of Johannesburg and the Gauteng health department.

At the operational level, the City manages the day-to-day functioning of the facility such as medicine collection, patient queues, flow of people through the clinic and the basic organisation of service delivery. These are the most immediate points of contact for patients navigating the system.

Less visible is the Gauteng provincial health department’s role in setting service standards that determine what care must be available, where clinics are located and what services are offered. It also defines operating hours and service targets, shaping how services are organised over time.

Behind this sits a further layer of complexity: The provincial system supplies pharmaceuticals, while the City is responsible for managing how these medicines are stored and handled at facility level. This includes cold-chain storage, routine stock management and alerting the provincial department to potential stockouts.

It also extends to systems such as the Central Chronic Medicine Dispensing and Distribution programme, where chronic medication is pre-packed and distributed outside of clinics. The City must actively help run this programme to make sure patient targets are met both inside clinics and at outside pick-up points.

At the same time, provincial authorities approve and manage budgets, subsidise operations and participate in district-level governance structures such as district health councils.

In this sense, the functioning of a single Johannesburg clinic is often shaped through multiple administrative, financial and logistical circuits that extend far beyond the facility itself.

Even the presence of healthcare workers reflects this division of responsibility. Staff in Johannesburg are employed by the provincial department but are temporarily assigned to City-managed facilities. In this respect, they fall under the City’s day-to-day supervision.

For most patients, this complex division of responsibility is rarely visible.

It is only questioned in moments of strain or breakdown, for instance when queues lengthen, medicines run out or access is disrupted. This is where the SLA shifts from a technical agreement into a site where accountability is contested.

Legal showdown

This contestation is well illustrated in a legal showdown in the South Gauteng High Court in Johannesburg.

In November 2025, health activist organisation Treatment Action Campaign (TAC) and other applicants brought an urgent application against the National Department of Health, the Gauteng Department of Health and the City of Johannesburg.

They sought an order requiring the state to restore access to Yeoville and Rosettenville clinics, which they argued had been effectively closed to certain patients between early September and early November 2025.

Lawyers for the national and provincial departments relied on the SLA to argue that responsibility for the blockades lay with the City because it manages the clinics. Therefore, the provincial department could not be held accountable for what occurred outside clinic gates.

The court disagreed.

Judge Stuart Wilson said the SLA “outsources nothing”. Instead, it assigns management of clinics to the City while preserving the provincial department’s oversight responsibilities.

“On any reasonable interpretation,” he said, “the service-level agreement embraces a role for the provincial department in stopping xenophobic vigilantes from preventing those without South African identity documents from using the clinics.”

Wilson emphasised that all three spheres of government must work together to ensure that reasonable measures are taken in restoring access to healthcare services as envisioned in section 27 of the Constitution.

The way forward

The judgment applied only to the two clinics at the centre of the urgent application. But for public interest law centre SECTION27, which represented the TAC, the case was always intended to have broader implications.

“Our case is in two parts,” said Khuselwa Dyantyi, a health rights attorney at SECTION27. “Part A was an urgent application because specific facilities were affected by vigilantes, so we needed an immediate remedy. Part B is seeking relief that would apply to facilities across the entire province.”

The matter has already been enrolled and is expected to return to court later this year. The court will then consider whether the obligations identified in the urgent application should extend beyond the two clinics at the centre of the dispute.

Asked about accountability and service disruptions, Gauteng Department of Health spokesperson Steve Mabona said the department has protocols in place to manage disruptions to service delivery.

He added that, where issues cannot be resolved immediately, patients are redirected to the nearest facility. Complaints can be lodged through clinic complaint boxes, the nurse in charge, the National Health Hotline or the department’s email channels.

For Dyantyi, however, the principle established by the judgment is already clear.

“The buck stops with the province. They can make these arrangements to ensure services run effectively, but at the end of the day they are responsible,” she said.

So what will be at stake in November?

On 4 November 2026 South Africans will go to the polls in the country’s latest round of local government elections.

In most places these elections will have no direct impact on primary healthcare services – since the provision of these services is a provincial responsibility. The exception to this is the three big Gauteng metros and the City of Cape Town where SLAs are in place that delegate some provincial functions to the metros. If you are voting in one of these metros in November, your vote may well affect the quality of healthcare services you receive at public sector clinics or hospitals.

What will be at stake in these elections is environmental health. That is because no matter where in the country you live, your local government is responsible for environmental health in your area. We will turn to this issue in the next article in this series. DM

Disclosure: An employee of SECTION27 is quoted in this article and SECTION27 was involved in litigation mentioned in this article. Spotlight is published by SECTION27, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council and subject to the South African Press Code.

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