South Africa has developed an innovative mid-level medical worker model that can contribute substantively to the development of quality district level health care. These clinical associates entered the South African job market in 2011 and have reportedly been received favourably. The first cohorts performed well on local and national examinations, with pass rates >95%. They have demonstrated confidence and competence in the common procedures and conditions encountered in district hospitals; reportedly fitted in well at most of the sites where they commenced working; and made a significant contribution to the health team work, resulting in a demand for more such health workers. Universities and provinces involved in producing clinical associates are enthusiastic and committed. However, priorities are to: establish sustainable funding sources for training and deployment, provide adequate supervision and support, monitor the initial impact of the new cadre on health services, and manage the sensitivities of the medical and nursing professions around scopes of practice and post levels. Longer-term concerns are national leadership and support, scaling up of training, the development of career pathways, and the improvement of working conditions at district hospitals.