INTRODUCTION

The health of South Africans is poor, relative to the country's economic development and health care expenditure (Blecher et al. 2011; Coovadia et al. 2009). The country is faced with the coexistence of ‘explosive HIV and TB epidemics, a high burden of chronic illness, mental health disorders, injury and violence-related deaths as well as a silent epidemic of maternal, neonatal, and child mortality’ (Lawn and Kinney 2009: 2). Life expectancy has declined over the past decade (largely because of the HIV epidemic), there is insufficient progress towards the achievement of the Millennium Development Goals (MDGs), and health system performance is sub-optimal (Chopra et al. 2009; Rispel and Kibua 2011). Gender, race and geographical location remain the key markers of social and economic vulnerability and of poor health outcomes (Coovadia et al. 2009). Despite many supportive health policies and significant progress in social service development, stark health inequalities remain between the rich and the poor and between urban and rural dwellers (Harris et al. 2011; Padarath and English 2011).

In response to these problems, the minister of health signed the Negotiated Service Delivery Agreement (NSDA) for the health sector in October 2010. In terms of the NSDA, the four strategic outputs for the health sector are: increasing life expectancy; decreasing maternal and child mortality; combating HIV & AIDS and decreasing the burden of disease from tuberculosis; and strengthening health system effectiveness. Figure 1 shows the linkages between intended health care reforms and improvement in health outcomes.

In the past two years, a number of policy initiatives to strengthen the South African health system have been launched by the national Department of Health. These include the re-engineering of primary health care; improving human resources for health, notably the revitalisation of the nursing profession; the introduction of compulsory accreditation of all health facilities and the proposed national health insurance (NHI) system, the last-named having received the most media attention. As can be seen from Figure 1, these initiatives have their origins in the NSDA.