The dawning of democracy in South Africa provided the opportunity for a broad range of new policies, including in health and mental health. The Mental Health Act of 2002 embodied much needed transformation in the sector. The Ekurhuleni Declaration of 2012 articulated a comprehensive and compelling vision for mental health. Nevertheless, shortly thereafter the Life Esidimeni tragedy occurred, with the death of more than 140 individuals with mental illness, exposing a range of quality deficits. This demonstrated that there is a disjuncture between the reality on the ground and the ideals of mental health policies and visions. Thus, renewed attention to strategy and implementation is needed.