Health Promotion in a Re-Engineered Primary Health Care in South Africa

Hans Onya, International Union for Health Promoation and Education Elected Member would like to share some of the exciting work that is happening in health promotion in South Africa.

Health Promotion qualifications can now be accredited by the Health Professional Council of South Africa (HPCSA) following a re-engineering of the Primary Health Care (PHC) approach in South Africa. The Health Professions Act Section 16 now allows for universities to apply to the HPCSA to have their courses accredited. At the moment, the HPCSA Environmental Health Practitioners Board regulation relating to registration is applied to Health Promotion Practitioners. Effort is underway to establish a separate HPCSA Board for Health Promotion.

This development was preceded by a Health Promotion Competencies Round-table meeting held on 20 March 2014 at the School of Public Health in the University of the Western Cape (UWC), South Africa. The main aim of the meeting was to build consensus on what health promotion competencies are needed in South Africa. The outcome of the round table discussion was an identified set of core competencies for health promotion practitioners in South Africa; a delineation of health promotion training; and the identification of strategies to bridge the gap between health promotion practitioners, policy makers and training providers. Recommendations from this meeting were submitted to a Ministerial task team that established the scope of practice for entry-level Health Promoters after extensive consultations. This level of Health Promoters function as Community Health Care Workers (CHWs) in the re-engineered PHC.

In line with the World Health Organization’s (WHO) advocacy for the revitalization of Primary Health Care, and more than 30 years after its inception in the Declaration of Alma Ata in 1978, the South African Government developed a 10 Point Plan to transform the health system. Central to this transformation is the strengthening of PHC as the backbone of health service delivery.

A major policy development which aligns with the objectives of the 10 Point Plan to “overhaul the health care system and improve its management” (NDOH, 2010) is the PHC re-engineering strategy based on the Negotiated Service Delivery Agreement (NSDA) signed by the Minister of Health and numerous other Cabinet ministers and Provincial  Members  of the Executive  Council (NDOH, 2010). The NSDA sets out a plan to achieve the Government’s goal of ‘a long and healthy life for all’. PHC re-engineering is key to the success of the NSDA implementation process and seeks to shift the PHC system from a largely passive, curative, vertically and individually oriented system to one with a more proactive, integrated and population-based approach composed of multi-disciplinary teams and a national school-based PHC system led by nurses (Nursing Impact, 2011).

Of the three main types of health facilities available within a district – district hospitals, community health centres and clinics, each clinic has a PHC team consisting of facility and community-based outreach components. The outreach teams consist of at least a professional nurse, and an enrolled nurse and 4-6 community health care workers, who are responsible for 1000-1500 households (approximately 6 000 people). Doctors and PHC nurses support the outreach teams and see the complex clinical cases. The presence of outreach teams within communities is expected to create an enabling environment for behaviours that facilitate health, empower communities to direct local resources, and give them a voice in what happens.

What are lessons learned to date? In order to most effectively influence the health outcomes of their clients and communities, CHWs must balance their attention and resources amongst a medical, lifestyle/behavioural, and a socio-environmental approach to promoting health. These three approaches each target a specific set of health determinants and should be incorporated as core areas of the CHWs work as a means of developing personal skills and public policies that support healthy choices and reduce individual risk factors as follows:

  • Applying the lifestyle/behavioural approach for CHWs involves incorporating a variety of complementary health promotion strategies into their core functions, including health education, health communication, brief interventions, self-help and mutual aid, self-care, and healthy public policy;
  • Applying the socio-environmental approach to health promotion yields key strategies that include community development, community economic development, healthy public policy, and creating environments that are supportive of health.

In addition to incorporating key health promotion strategies into the mandate of CHWs, the core values of health promotion have to be embedded in the design and operation of community health intervention programmes, themselves. Standards and guidelines that support the values of empowerment, public participation, addressing the impact of the broader determinants of health, reducing social inequities and injustice, and facilitating intersectoral collaboration should be provided. Based on the South Africa experience, other countries within the Africa Region are encouraged to move towards Health Promotion Accreditation and re-engineering of PHC.


  1. National Department of Health. Re-engineering primary health care in South Africa: Discussion document. Pretoria: National Department of Health; 2010.
  2. National Department of Health. National Strategic Plan 2010/11-2012/13. Pretoria: National Department of Health; 2010.
  3. Nursing compact. National Nursing Summit: April 2011. Accessed, April 2015.
  4. Tracey Naledi, Peter Barron, Helen Schneider. Primary Health Care in SA since 1994 and implications of the new vision for PHC re-engineering 2. SAHR 2011.
  5. Van Rensburg HC, Harrison D. History of health policy. In: Harrison D, editor. South African Health Review, 1995. Durban: Health Systems Trust; 1995.
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