Thirty years into democracy, South Africa’s health system is rated as the best-developed on the African continent and is geared towards closing the divide between the public and private healthcare sectors, but the country still faces immense social, economic and health inequities which thwart the fulfilment of universal health coverage. In tracing the journey of South Africa’s health system development to highlight persistent challenges and future directions for solutions, key issues such as the various negative determinants of health, the burden of disease, patients’ experience of care, the paucity of strategic health information, and the dearth of human resources for health, surface as a tableau of polycrisis. Integrated, multi-sectoral approaches to promote health as a human right, well-governed implementation of policy to holistically address gaps in service delivery and data management, and authentic community participation in monitoring health system performance can support action for reform to improve its quality, responsiveness, efficiency and resilience.