Community health worker models in South Africa: a qualitative study on policy implementation of the 2018/19 revised framework

By  Joshua Murphy  Dr. Aneesa Moolla  Sharon Kgowedi  Constance Mongwenyana  Sithabile Mngadi  Nkosinathi Ngcobo  Dr. Jacqui Miot  Dr. Denise Evans  Dr Sophie Pascoe  |  | 


South Africa has a long history of community health workers (CHWs). It has been a journey that has required balancing constrained resources and competing priorities. CHWs form a bridge between communities and healthcare service provision within health facilities and act as the cornerstone of South Africa’s Ward-Based Primary Healthcare Outreach Teams. This study aimed to document the CHW policy implementation landscape across six provinces in South Africa and explore the reasons for local adaptation of CHW models and to identify potential barriers and facilitators to implementation of the revised framework to help guide and inform future planning.


We conducted a qualitative study among a sample of Department of Health Managers at the National, Provincial and District level, healthcare providers, implementing partners [including non-governmental organizations (NGOs) who worked with CHWs] and CHWs themselves. Data were collected between April 2018 and December 2018.


We conducted 65 in-depth interviews (IDIs) with healthcare providers, managers and experts familiar with CHW work and nine focus group discussions (FGDs) with 101 CHWs. We present (i) current models of CHW policy implementation across South Africa, (ii) facilitators, (iii) barriers to CHW programme implementation and (iv) respondents’ recommendations on how the CHW programme can be improved. We chronicled the differences in NGO involvement, the common facilitators of purpose and passion in the CHWs’ work and the multitude of barriers and resource limitations CHWs must work under. We found that

models of implementation vary greatly and that adaptability is an important aspect of successful implementation under resource constraints.


Our findings largely aligned to existing research but included an evaluation of districts/provinces that had not previously been explored together. CHWs continue to promote health and link their communities to healthcare facilities, in spite of lack

of permanent employment, limited resources, such as uniforms, and low wages.


Keywords: Community health workers, implementation science, qualitative research, primary health care


Key Messages

  • South Africa’s community health worker (CHW) programme has been a vital part of healthcare service delivery in South Africa for

decades. The programme has existing variation in models of implementation but is guided by a strong national framework since

2011, recently revised in 2018.

  • Despite the programme’s long history, there are still many challenges to optimal implementation, including limited resources, incomplete staff complements, inconsistent use of data, safety concerns and few pathways for professional development.
  • South Africa’s National Health Insurance, among other objects, seeks to ensure Universal Health Coverage and optimal implementation of the CHW programme is an important part of that policy and towards improving the quality of primary health care in South Africa.

Publication details

Oxford Health Policy and Planning