Although South Africa has, since 1994, developed an impressive compendium of financial management policies and regulations, public expenditure management remains a challenge. Nationally, the Public Finance Management Act, 1999 (PFMA) forms the basis of financial management in the public service. In the municipal sphere, which is the heart of public service delivery, the PFMA is supported by the Municipal Financial Management Act, 2003 (MFMA). Yet, financial management in all three spheres of government remains a challenge. This article presents a case study on one Metropolitan area's health department in the Gauteng province, as a quest to highlight the magnitude of the challenge of public expenditure (mis-)management in the South African public sector. The region has over a number of years received qualified audit statements from the office of the Auditor-General with no significant improvements registered. In this article, it i