Attacked by the press and dogged by controversy, South Africa's health minister, who will be speaking at next week's NHS Confederation conference in London, is, nonetheless, a gutsy reformer. And she's not afraid to take on her critics. Pat Sidley reports

Nkosazana Zuma, South Africa's first post-apartheid minister of health, attracts a bad press: her achievements seldom receive as much attention as her problems. She has been given the task of tackling the legacy of apartheid's health system, which systematically ensured that the white minority received good healthcare, while the black majority would be condemned to poverty and disease.

Her department has had to grapple with spiralling numbers of AIDS cases - the fastest-growing rate of HIV in the world - tuberculosis, low immunisation rates, high infant mortality and maternal morbidity rates, malnutrition and utter deprivation.

In 1996, a survey conducted by the Henry J Kaiser Foundation found that only about 20 per cent of the black population had running water in their homes, compared with 100 per cent of whites. Around 60 per cent of black homes had no electricity. In rural areas this figure is higher. Nearly a quarter of black South Africans said they were too poor to feed their pre-school children. The cost of care and the availability and cost of transport were major barriers to improved healthcare for black South Africans.

South Africa spends about 8.5 per cent of its GDP on healthcare. Between 60 and 70 per cent of this is spent in the private sector and the rest in the public sector. But only 20 per cent of the country's population pay privately for healthcare. This imbalance is reflected in the spread of health professionals. More than half (57 per cent) of the country's doctors work in the private sector, as do 87 per cent of dentists and 95 per cent of pharmacists.

This, and worse, was the environment Dr Zuma was brought up in. The eldest of eight children, she was midway through her medical degree at the Natal University Medical School - which taught black students; another school taught white ones - when, in the turbulent 1970s, she fled the country for the UK. She began her degree again and completed it at Bristol University. She also has a diploma in child health from Liverpool's School of Tropical Medicine. Yet the pharmaceutical industry in South Africa and several in the white healthcare establishment pretend to believe she has no medical qualifications.

Armed with her UK qualifications and her membership of the African National Congress she returned to Africa, worked in various hospitals, and took part in the ANC's guerrilla effort aimed at ending the apartheid regime.

Dr Zuma has several children, the youngest of whom was six when she had to leave them in Durban and move between Pretoria and Cape Town as health minister. She is reportedly one of several wives in a polygamous marriage with noted ANC official Jacob Zuma. She has consistently refused to be drawn on the issue - although she did once say that she is his only 'legal wife'.

After the 1994 elections, Dr Zuma was called by President Nelson Mandela to be minister of health, one of only two women in the first cabinet. Aside from her political and medical qualifications, being a woman and a Zulu made her an ideal choice.

But Dr Zuma stumbled into problems with the media from the start. A sceptical white press and white medical establishment were never going to give her an easy time.

The first run-in was over her apparent move towards accepting a national health system proposed by Australian healthcare expert John Deeble, following secret discussions.

By the time the news leaked to the press, the plan was far advanced. But a commission of inquiry appointed to assess the affordability of national health systems recommended a primary healthcare system run from public funds and a mix with the private healthcare system, using the latter to spread some of the resources.

Dr Zuma's next major brush with the press was the scandal of the Broadway-style musical commissioned by her to spread an anti-AIDS message. It cost in excess of£1.25m (R10m), but failed to meet tendering requirements, used European Community money without EC permission and carried a flawed message.

Her lack of an AIDS policy keeps coming back to haunt Dr Zuma. UNAIDS, working under the auspices of the United Nations, estimates that one in ten adults in South Africa are HIV-positive. Another bout with the media and medical establishment followed her backing of a controversial would-be AIDS 'cure' known as Virodene.

This was the name given to a formula invented by two Pretoria research technicians, neither of whom were medical doctors. It consisted largely of an industrial solvent and the researchers claimed it killed the HIV virus. They did not design protocols or submit it for ethical approval but nevertheless supplied it to people who were HIV positive. They asked the cabinet for research funds and were offered£375,000 (R3m). The introduction of the drug was backed both by Dr Zuma and by deputy president Thabo Mbeki.

The Medicines Control Council, South Africa's drug regulatory body, stepped in to stop the sale of the untested product. Two committees of academics inquired into the controversy and condemned the lack of research. The MCC believed the industrial solvent to be potentially dangerous and the issue became a political row between the MCC and the ANC.

Dr Zuma's relationship with the media is still poor despite the department of health's£375,000 contract with a public relations firm. Insiders claim that well-rehearsed press conferences are blown by Dr Zuma's short temper and her inability to deal with a questioning and sceptical press.

But all this fails to take into account the immense amount she has done to improve the desperate state of South African healthcare.

She has overseen the introduction of the first stages of a free primary healthcare system, which has provided 5 million people with access to healthcare who may not have had such access before.

Dr Zuma has introduced free healthcare for pregnant women, women with children, and children under six.

After a bad start, dogged by corruption, a primary school feeding scheme now nourishes 4.9 million children - about 78 per cent of the children targeted for assistance.

And she has introduced one of the world's most liberal abortion laws, providing abortion free and virtually on demand. More than 40,000 women have so far used the service, made necessary by, among other things, the 400 annual deaths from back-street abortions.

This law is now being contested in court as a possible prelude to a constitutional court challenge by a Christian pro-life lobby. But department of health officials say they are confident the challenge will not succeed and they are determined to ensure that women have the option of abortion.

Dr Zuma has also embarked on a programme of building, repairing and upgrading clinics. By the end of last year, 204 new clinics had been built, 38 upgraded, and residential units had been added to 364 existing clinics, the department of health says.

And Dr Zuma is the first minister of health in South Africa to take on the tobacco industry and the multinational drug companies. She has implemented severe restrictions on tobacco advertising and a complete ban is expected. She has increased the tax on tobacco products and made it illegal to sell them to children.

Dr Zuma has drawn up an essential drugs list and guidelines for prescribing in hospitals. She has also changed the formerly very corrupt marketing practices and incentives by which branded drugs reached the market in South Africa, and introduced incentives for prescribing generic drugs.

These moves have left no section of the healthcare industry untouched. Dispensing doctors - 5,000 in South Africa, many of them black, are licensed to dispense - feel betrayed by changes that will ensure that it is less profitable to dispense drugs than it used to be.

Pharmacists, who had the same profit motive - a 50 per cent mark-up on a wholesale price - now find that they, too, will be faced with flat-rate charges.

Doctors believe their autonomy is being reduced because pharmacists must inform the public that a cheaper generic drug may be available.

Dr Zuma is determined, despite the drug industry's international muscle - and current court interventions - to open up the market to international tendering and parallel importing.

It is in this area that another confrontation with the MCC blew up - one that proved terminal. Dr Zuma appointed an inquiry team with international experts to look at the structure and function of the council. The inquiry reported that the MCC should be closed and restarted with a less potentially compromising relationship with drug companies. MCC officials and the chair were fired. New full-time officials have been appointed to see drugs onto the market while a new council is set up.

But despite the controversy, Dr Zuma's achievements have made her popular among her constituency and within her party. And she has the backing of both President Mandela and Thabo Mbeki.

Her battles are far from over. The spread of AIDS and TB has reached crisis proportions. Meanwhile, young doctors, both black and white, are angry at her introduction of mandatory community service to get them to work in unpopular areas. And only last month, Dr Zuma sacked her equally controversial director general, Olive Shisana.

But Dr Zuma's now legendary stubborn streak will probably ensure her survival.