South Africa is discussing universal healthcare. But for patients facing broken infrastructure, the real question is much simpler: can a health system function when the basic things people need to survive are missing?
No patient should have to cross a flooded river to get to a clinic. Hospitals should not have trouble keeping the lights on. Insulin should not be harder to use just because electricity is unreliable. Clean water should never be seen as optional in healthcare.
Yet these are the realities being raised as South Africa moves into the next phase of its National Health Insurance (NHI) journey.
The South African Medical Association (SAMA) has warned that the country's infrastructure deficit, including water shortages, broken equipment, staff shortages, electricity problems and poor governance, is undermining the possibility of delivering universal healthcare in practice.
SAMA chairperson Dr Mvuyisi Mzukwa argues that the country is not simply dealing with a shortage of money. It is dealing with the condition of the system into which that money would have to go.
As he put it, "NHI ignores all these other pillars of a healthcare system.”
The NHI Act was signed into law in May 2024 with the stated aim of achieving universal access to quality healthcare. Government describes implementation as phased, with health-system strengthening forming part of the process.
But the NHI is fundamentally a financing and purchasing framework. It cannot, by itself, repair a leaking hospital roof, replace a broken X-ray machine, train and retain enough healthcare workers or make water come out of a clinic tap.
And that is where the conversation becomes less about policy and much more about the person sitting in the queue.
Before the doctor, there is the journey
The waiting begins long before the first clinic door opens, under a sky still thick with the damp cold of a rural Eastern Cape dawn. By 3am, a small crowd has already gathered outside the gates of a village clinic.
Among them is a pregnant woman who spent the last two hours navigating a dirt track and wading across a swollen river because the footbridge washed away years ago and was never replaced.
She sits on a plastic crate, shivering, knowing she will likely not see a nurse until mid-afternoon. If she is lucky, the clinic will have electricity to keep the vaccines cold. If she is luckier still, water will flow from the taps.
This is the visceral reality of South African healthcare, a world far removed from the polished boardrooms of Pretoria where the National Health Insurance (NHI) Act is debated as an abstract financial cure-all.
Signed into law in May 2024, the NHI is marketed by the state as a historic equaliser, a grand promise of universal coverage.
But as the system inches through legal delays and Constitutional Court challenges, frontline doctors and exhausted patients are asking a much harsher question: how do you build a flagship healthcare system when the very pipes, wires, and walls of the existing infrastructure are collapsing?
The South African Medical Association (SAMA) has increasingly broken polite diplomatic protocol to call out this contradiction. Mzukwa has repeatedly warned that the state is attempting to fund its way out of a systemic crisis of governance.
The NHI is fundamentally a financing framework, a massive state-run purchasing fund. It can redistribute money, but it cannot fix a burst water main, replace a rusted X-ray machine, or force a dysfunctional municipality to keep the lights on.
By treating healthcare as a purely financial equation, critics argue, the government is deliberately avoiding accountability for the physical decay of its facilities.
In May 2026, the Commission for Gender Equality exposed chronic water disruptions at Settlers Hospital in Makhanda. When the system breaks down, human dignity goes with it.
Photos went viral showing mothers carrying plastic buckets of water into pediatric and maternity wards just to wash their sick children. Hospital bosses blamed "ageing infrastructure" and "outdated water maps" as fancy explanations for a system that left nurses unable to even wash their hands.
When a hospital loses water, it stops being a place of healing and becomes a place where diseases spread.
Mzukwa previously warned that when municipal water systems fail, preventable stomach illnesses spike. The government’s failure to fix basic plumbing is literally making its own citizens sick.
Even if you manage to get inside a clinic, there is rarely enough help. While the state promises "universal care", South Africa's public hospitals are in a permanent state of emergency.
To understand why the queues are so long, you have to look at the math. Healthcare experts say that for a medical system to be safe, a community needs at least one doctor for every 400 people.
But in South Africa’s public health system, that same single doctor is stretched across more than 3,300 people.
This means a single, exhausted doctor is often left completely alone to manage an entire emergency room overnight, making life-or-death decisions with zero backup.
The rot extends to the electrical grid. Inside the hospital walls, the stakes are even higher. When the power cuts out and backup generators fail because a local government contract ran out of fuel, operating theatres go pitch black. Emergency surgeries simply stop
This fragmentation of governance was a bitter recurring theme at the 2026 Food Indaba, where civil society speakers pointed out that South Africa’s political elite excel at drafting world-class policies on paper while utterly failing the logistics of implementation.
Departments operate in silos: the Ministry of Health cannot fix the roads that ambulances use, nor can it fix the municipal pumps that supply its clinics.
Because of this chaos, patients endure a brutal ten-hour gauntlet. They wake up in the dark, walk for hours, sit in the heat, and are frequently turned away at 3pm because the clinic is short-staffed or the only diagnostic machine has broken down.
For an elderly grandparent or a sick child, this isn't just an inconvenience; it is a life-threatening barrier that makes them give up on treatment entirely.
When the government celebrates the NHI as a victory for equality while ignoring the rot in the foundations, it feels like a cruel joke to those on the ground. You cannot have a healthcare promise without the plumbing.
Until the state does the unglamorous work of fixing leaking roofs, hiring permanent nurses, and ensuring clean running water, the NHI will remain an expensive illusion.
That is precisely where the conversation surrounding the NHI must focus.
Instead of asking, "How will healthcare be funded?", the real focus should be on practical patient care: Where will the patient sit? Who will treat them? Will the medical equipment be functional? Are clean water and electricity available? How will they travel home? And will their medical records be accessible when they return?
vuyile.madwantsi@nationalmg.co.za