ANC local government election manifestos and the rural health crisis — when service delivery failures become fatal

South Africa’s rural health crisis is both a moral indictment and a governance failure that successive local government election manifestos of the ANC have acknowledged rhetorically but failed to resolve materially. In provinces such as the Eastern Cape, KwaZulu-Natal and Limpopo, mortality and morbidity remain significantly higher than national averages. Infant and under-five mortality rates in these provinces are often 30% to 50% higher than the national figure, while maternal mortality regularly exceeds 120 deaths per 100,000 live births, compared with far lower rates in urbanised provinces.

These disparities are not accidental. They are the predictable outcome of persistent socioeconomic deprivation, corruption, weak municipal service delivery, uneven health coverage and the continuing burden of HIV/Aids in rural communities.

Nationally, South Africa has made measurable progress. Life expectancy has improved from the mid-fifties in the early 2000s to the mid-sixties today, largely due to the expansion of antiretroviral therapy, improved HIV management and broader access to primary healthcare. Yet this aggregate success conceals a deep rural-urban divide. Rural districts still experience preventable maternal deaths, delayed emergency obstetric care, missed immunisations and underresourced clinics, undermining national health gains and reinforcing inequality.

The ANC’s local government election manifestos consistently position service delivery as central to improving quality of life. The 2021 local government election manifesto pledged “safe, healthy communities” through better basic services, accountability and capable local governance. The 2024 manifesto reiterated these commitments, foregrounding water, sanitation, healthcare access and the National Health Insurance (NHI) as mechanisms to reduce inequality. However, what remains absent is a clear articulation of how municipalities (the weakest link in the governance chain) will be capacitated, monitored and sanctioned to deliver the foundational services upon which health outcomes depend.

A concrete example illustrates this disconnect. In the OR Tambo District Municipality in the Eastern Cape, repeated water infrastructure failures have left clinics and surrounding communities without reliable access to clean water for weeks at a time. Clinics in rural wards have reported intermittent closures due to water shortages, staffing gaps and lack of basic infection-control resources. In such contexts, maternal health services are compromised not by a lack of policy intent, but by municipal collapse due to mismanagement and corruption. Women in labour are forced to travel long distances to alternative facilities, often without reliable transport, contributing directly to preventable maternal and neonatal deaths. These realities are absent from manifesto commitments that speak broadly of “improving service delivery” without addressing municipal incapacity as a structural health risk.

The ANC’s manifestos correctly identify water, sanitation, electricity and housing as part of the “social wage”, yet they stop short of acknowledging how chronic failures in these areas translate into excess mortality in rural communities. Poor sanitation and water insecurity drive diarrhoeal disease among children. Inadequate roads and unreliable emergency services delay obstetric referrals. Staffing vacancies (in some rural municipalities exceeding 30% for professional nurses) weaken continuity of care, undermine HIV and TB treatment adherence and erode trust in the health system.

This gap becomes especially concerning in the context of NHI. While NHI is a national policy framework designed to equalise access to healthcare, its effectiveness is fundamentally dependent on functional local systems. A clinic without water, electricity or staff cannot deliver quality care under any financing model. Municipal failure therefore directly undermines NHI’s promise, particularly in rural areas where the public health system is often the only option. The ANC’s manifestos celebrate NHI as a transformative reform, yet fail to sufficiently confront the reality that without fixing local government, NHI risks reproducing existing inequalities rather than resolving them.

What emerges is a pattern of well-intentioned but insufficiently grounded policy commitments. The language of accountability, partnership and community development is repeated across manifestos, but rural health outcomes suggest that implementation remains weak. Auditor-General reports consistently show rural municipalities struggling with financial mismanagement, vacant senior posts and collapsing infrastructure. These governance failures are not abstract; they manifest in higher maternal mortality, avoidable child deaths and shorter lives in rural South Africa.

If the ANC is serious about closing the rural-urban health gap, future local government election manifestos must move beyond aspirational language. They must commit to measurable rural health targets linked explicitly to municipal performance: reductions in maternal and under-five mortality at district level, minimum staffing norms for rural clinics, guaranteed water and sanitation standards for all health facilities and enforceable consequences for municipal failure. Without this shift, rural health inequality will persist, and service delivery failures will continue to claim lives silently, far from the spotlight of national statistics. DM

Awam Mavimbela is a PhD candidate at the University of the Free State, a social justice and mental health researcher and a columnist. His work focuses on socioeconomic development, palliative care, mental health, local governance and social security policy in South Africa.