South Africa (SA) commands financial health care resources comparable to Brazil, Mexico and Thailand. Despite spending similar amounts in the public sector (3.5% of gross domestic product (GDP) in terms of purchasing power parity, these and other countries have far better health outcomes than SA on almost all measures including life expectancy and maternal mortality (Table I). (1,2) While the combined impact of HIV and tuberculosis (TB) on all-cause mortality has been immense, this only partially explains the plummeting life expectancy in SA from 63 years in 1990 to 45 years in 2007. Furthermore, SA is one of only 12 countries worldwide with a marked reversal of maternal and infant mortality, reflecting the complex epidemiological transition underway. (3) An increasing percentage of the population now dies from chronic, non-communicable diseases such as vascular illness, diabetes and cancers and from violence and injury. (4) Despite the global economic crisis, annual national SA government health expenditures are projected to rise by an average of 7.1% per year between fiscal years 2009/10 and 2012/13, with costs close to ZAR 100 billion for 2009/10. (5) After a decade that posed many challenges, issues of health care delivery and services are now squarely on the table. Given that 85% of the population depends on the public sector, in times of fiscal restraint two broad questions that should be addressed are: will the public be getting good value for their health care rand, and what criteria will be used to inform the allocation of resources that will ensure equal access to high quality health care?