Toilets Of Despair: Dirty, broken Toilets at Clinics Speak of Systemic Neglect

Read Time: 10 minutes

For World Toilet Day, our community journalists, Molefi Sompane, Montsho Motlale and Sandile Mbili visited 31 primary health facilities and spoke to 313 patients across the Free State, Limpopo and KwaZulu Natal, assessing the state of sanitation. We’ve chosen to use pictures which won’t make readers queasy.

This story was made possible with funding from OpenUp and Africa Data Hub. The visual and data graphics featured were created by the OpenUp team.

Across South Africa, accessing healthcare at primary health facilities is often an act of indignity—from long queues and overburdened staff, to the simple act of using a restroom. Clean bathrooms in many clinics are a rarity, not the standard. And they’re not just poorly maintained, but actively hazardous. For patients, using the toilet can be a dehumanising experience. 

“These toilets have flush water but they are dirty and the floors are always wet. They are infectious because there is no toilet paper, soap, sanitiser and hand washing basin. If have a choice I will not come to Zone 3 Clinic again.”-Rami*, 24, Limpopo

Rami* is among 313 patients who shared their stories with our community journalists in Limpopo, KwaZulu-Natal, and the Free State as part of a survey of 31 primary health facilities to assess sanitation conditions.

The evidence is not just anecdotal. The findings reveal a picture of neglect. Most toilets in the facilities visited don’t work, lack basic supplies like soap and toilet paper, and fail to provide adequate handwashing stations. 

An issue of dignity and human rights

I was very disappointed when I went to the reception at Halley Stott Clinic to ask for toilet paper since there was none in the men’s bathroom. I was told that there was no toilet paper. One lady who was a patient felt pity for me and went and got some from the ladies toilet. After finishing my business I needed to wash my hands with soap but it was not provided.-Mandla, 34, KZN

This lack of hygiene isn’t just inconvenient—it’s a harsh reminder of systemic neglect. “A lack of adequate sanitation affects patients’ rights to equitable care and access, rights that are enshrined in the Constitution”, says Morongwa Ntini, a researcher at the Treatment Action Campaign (TAC). 

Our findings align with TAC’s clinic monitoring programme, Ritshidze. In a national report assessing 471 facilities and over 25 000 patients,  53% rated the toilet facilities as ‘bad’. “The data is alarming, and we can see a lot needs to be done”, says Ntini. 

Safe toilets for all by 2030 is one of the targets of Sustainable Development Goal 6, but ‘attention is given to other factors like medicine stockouts and staff shortages’, says Ntini. “A hygienic environment deserves attention.” 

“Sanitation is an issue of dignity”, says Nina Benjamin, a programme manager at the Labour Research Service (LRS), who facilitated a pilot social action project at the Meadowlands Clinic in Soweto.  

“We’ve gotten so used to this type of service, nobody is questioning it any longer. The assumption is that people shouldn’t expect any better.” 

A public health failure

“My worry about these toilets of Moletjie Clinic is that there is no single piece of hygiene. It is unsafe using these toilets because you know you are a target of infectious diseases. For starters never enter a toilet here if you do not have your own toilet paper for there is none here.”-Lamson*, 68 , Limpopo

Of the bathrooms visited by our community journalists, 78% were unclean, with 40% showing visible faecal matter or urine on the toilet seat, walls, or floor. This is more than a cosmetic issue—it’s a public health crisis. 

“Inadequate sanitation in healthcare facilities increases the risk of infections,” warns Professor Nicola Page, Acting Head of the Centre for Enteric Diseases at the National Institute For Communicable Diseases (NICD). Diarrheal pathogens, respiratory viruses, and enteric viruses like intestinal worms thrive in such conditions, putting the most vulnerable patients—children under five and the elderly—at increased risk. 

“The place where one seeks healthcare should not be the place that places health further at risk,” adds Ntini.

“If the toilets are dirty, there is no toilet paper, soap or running water then the likelihood of increasing transmission of micro-organisms between people in these surroundings also increases.

There is also a greater chance of transmission to the staff at the facility, which puts further strain on the health system as a whole”, explains Page. 

Beyond this, says Ntini, it’s a barrier for people accessing services. “Imagine standing in a long queue for hours, then to be faced with a dirty toilet. Patients may not return to a facility, and it can result in them defaulting on treatment.” 

Psychological impact on patients

“I usually go to Tshelimnyama Clinic, and the clinic’s toilets are mobile toilets that do not have proper working door handles. Every time when you are inside you have to shout that you are inside before anyone even comes to open the door.”-Sibongile*, 22, KZN

“I am disgusted by these two roomed metal sheet toilet with no signs to show which room is for men and another for women. And there is no full privacy inside because doors do not close properly so some naughty people can peep through. I am unlikely to return.”-Chego* 34, Zone 3 clinic, Limpopo

For patients, poor sanitation impacts more than physical health; it takes an emotional toll.

In the facilities we surveyed in Limpopo, the sense of unease is stark: 90% of women and 82% of men report feeling unsafe when using the toilet. The picture in KwaZulu-Natal is also troubling, with 62% of women and 30% of men sharing the same concerns. These fears stem from various issues, with patients surveyed mentioning poorly located toilets outside health facilities, broken doors, and the lack of clearly demarcated spaces as key contributors.

This anxiety takes on deeper dimensions for marginalised groups. “What we’ve found is that trans men feel comfortable using the toilet of their choice, whether it’s labelled for men or women. But cleaners often accuse them of using the ‘wrong’ bathroom, leaving them feeling unsafe,” explains Ntini.

Benjamin argues that dysfunctional spaces foster hostility. “When people enter a space that’s dirty, they don’t feel respected or valued, and they lash out. A negative experience leads to negative behaviour,” she says, pointing to how poor conditions erode trust and civility.

These issues highlight the grim reality that poor sanitation is not just logistical, but also a barrier to care. “If people feel unsafe, what are the chances they’ll seek healthcare?” asks Ntini. 

Where the money goes-and doesn’t go

The Ideal Clinic programme, launched in July 2013 to improve primary healthcare, ahead of the National Health Insurance (NHI) rollout, includes cleanliness, availability of hygiene products, and functional sanitation facilities as foundational elements. Our survey findings and that of Ritshidze highlight a severe discrepancy between these standards and the reality on the ground. 

Achieving the Ideal Clinic goals requires good governance and a healthy budget. But the national health budget is shrinking. 

Several organisations-SECTION27, Rural Health Advocacy Project (RHAP) and TAC- advocate against budget cuts to the health sector, emphasising the need for sustained or increased funding to protect public health rights, which includes decent sanitation.  

“Provincial health budgets are under considerable pressure, driven by under allocation to compensation of employees. As this makes up 65% of budgets, shortfalls are being funded by deferring maintenance”, says Russell van Rensburg, director of RHAP.  He urges the national health portfolio committee to  ‘urgently convene all provincial departments to table their plans for ensuring this inhumane situation is resolved.’

South Africa’s health budget does not include a dedicated line item for sanitation; instead, it’s categorised under maintenance and infrastructure. This lack of explicit prioritisation has led to a patchwork approach to addressing critical issues like functional toilets and clean facilities.

“I don’t know how many times cleaners should clean toilets but sometimes you could see that this toilet has not been cleaned for days which eventually causes the foul smell.-Nurse, KwaDabeka Community Health Centre, KZN

“The problem is the replacement when soap, sanitisers and toilet papers get finished. It takes a long time for management to replace them. Even the cleaning staff is the problem, because when one of us no longer works due to retirement, resignation or death, she is hardly replaced and this creates a shortage.”-Jaqueline*, cleaner, Limpopo

“There must be a separate budget line item for sanitation to prevent funds from being redirected to other areas of priority”, says Ntini. “And we need to engage with users and staff to determine where areas of improvement are needed.” 

Getting patients involved is critical, says Benjamin, as ‘patients feel they don’t have a voice in public spaces.’

For now, the lack of safe, dignified sanitation continues to stand as a harsh reminder of systemic neglect—compromising health, dignity, and trust in South Africa’s public healthcare system.

None of the spokespersons for Limpopo, Free State, KwaZulu-Natal, or the national health department responded to requests for comment.-Health-e News

EDITOR’S NOTE: Each facility was visited once, and while the findings shed light on troubling patterns, they are not reflective of the entire province. The results, however, provide a snapshot of the widespread neglect of sanitation in primary health facilities. The patients’ experiences are their lived reality. 

We’d like to hear about your experience using the toilet at a primary health facility. Please take our survey

If you enjoyed this story, and would like to see more like this, please support our work