Introduction The 2015 United Nations sustainable development goals have underscored the importance of universal health coverage (UHC), a healthy, well-educated workforce and compliance with international occupational health and safety standards. This paper draws on key findings of a doctoral research study to explore the [dis] connexions between quality, governance and models of occupational health service (OHS) delivery in South Africa. Within the context of UHC, the paper will highlight key recommendations emerging from the study.

Methods The Human Research Ethics Committee provided ethics approval. The research used a combination of methods, which included a review of occupational health (OH) legislation and policy documents; in-depth interviews with 12 key informants; 11 focus group discussions in three South African provinces, and a web based survey of OHS practitioners. We used thematic content analysis to analyse the qualitative data and STATA to analyse the web based survey.

Results The study found diverse models of OHS delivery in South Africa, of varying quality, with an excessive focus on physical examinations to achieve legal compliance. Furthermore, OHS occupy a relatively low priority on the health reform agenda and are delivered in a fragmented and complex legislative framework. These quality and governance problems are exacerbated by a perceived lack of employer emphasis on OH, insufficient human and financial resources, and lack of specific quality of care standards for OH. The survey found that external assessment of OHS is associated with improved compliance with relevant legislation.

Discussion Improvement in the quality and governance of OHS delivery is essential to realise South Africa’s quest for UHC. While the exact nature and form of external assessment needs to be determined, there is need for nationally agreed upon standards for the delivery of OHS, implemented through a cohesive structure which is cost effective, sustainable, and mandatory without marginalising small to medium service providers.