The curtain on my long-standing career as a public health service employee after more than a decade spent championing the health rights of the most vulnerable, has drawn to a close. But it closes with sobering thoughts about what we have achieved and what we are yet to.
On 22 June 2026, my last day at our dental outreach outpost, the gap between where we are and where we should be was laid bare. The NHI has been hailed as the most significant and progressive health policy development of the decade. But some failures remain unheard and invisible, laying bare a system that consistently chooses to limp, so long as no one sees. On that day, a 44-year-old woman with a disability who uses a wheelchair was carried into our mobile truck, which was never built with universal access requirements in mind. What left me in deep reflection was the realisation that disability remains largely invisible in our healthcare system – an afterthought.
The same patient outlined a painful story of a healthcare system that ignores the barriers in her environment. Public transport is cheaper, but cannot accommodate someone using an assistive device such as a wheelchair. Private transport is suitable, but unaffordable for someone unemployed and surviving on a disability grant capped at R2 400, often used to support more than just the person living with the disability. This is the final blow dealt by a healthcare system blind to the socioeconomic and systemic barriers that shape healthcare access, wellbeing and dignity.
Her daughter would outline how, over a period of four months, they were sent back and forth over several visits under the guise of protocol and procedure, suffering and unable to function. The clinicians who attended to her were oblivious to the secondary trauma and to the debt trap they were unconsciously creating through expensive pre-healthcare costs. Though my outreach site was much closer and provided care at no cost, it fell significantly below the standard of providing Sarah*, living with a disability, the comprehensive care she so desperately needed and the dignity afforded many others who navigate environments not designed with universal access in mind.
A system not built for disabled people
Disability inclusion and universal access design principles, particularly in healthcare services and infrastructure design, are still treated as considerations instead of core pillars of planning and design. Sarah’s* reality is the reality of many people living with disabilities in South Africa, who continue to be traumatised and marginalised by a system that claims to prioritise them. They are best served by inclusive policies and systems, rather than exceptional programmes, that remain sideshows.
Access is not access when it ignores the reality that our systems, and the way we have designed them, continue to treat people living with disabilities as second-class citizens. Sarah’s* story cannot be normalised. It cannot be that the only way to dignity is through the highest bidder, and that if you cannot pay, you must accept that schooling, healthcare, work and social services will remain far from recognising and respecting your humanity first.
Universal access must include disability
While the debates around NHI implementation continue, let us not forget that it is not a panacea for a world that refuses to include others. Universal health access will remain incomplete without disability-inclusive design at its centre. Healthcare curricula need to include this in their content to ensure that healthcare professionals of the present and future are adequately equipped with universal healthcare system design and delivery expertise, so that their care does not exclude when it exists for the benefit of all. Disability inclusion is not an elective; it must be at the core of all that we plan and do. Easier said than done, but perhaps the times call for less saying and more listening, particularly to the voices of those we have marginalised, victimised and failed.
Sarah* is a pseudonym used to protect the patient’s identity. Any resemblance to, or association with any real person named Sarah, is purely coincidental and unintended.
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Dr Bulela Vava is an Atlantic Fellow for Health Equity in South Africa based at Tekano, Executive Director of the Public Oral Health Forum, a social entrepreneur and a rising voice for health equity.
