Implementation of Integrated Health Promotion in South African Primary Health Care Clinics and Communities: A Policy Brief

1. Introduction

Health promotion is an important part of South Africa’s primary health care (PHC) system (Department of Health [DoH], 2015; World Health Organisation [WHO], 1978). It is central to national efforts to prevent disease, save money, and deal with ongoing social and health inequalities (DoH, 2015; WHO, 2008). In the last ten years, national policies have focused more on integrating health promotion into regular PHC services and community programs, rather than treating it as something separate (DoH, 2015; National Department of Health [NDoH], 2018). Major reforms, including the National Health Promotion Policy and Strategy (2015–2019), the Ward-Based Primary Health Care Outreach Team (WBPHCOT) strategy, and community-oriented primary care (COPC), aim to institutionalise health promotion within PHC by embedding it into clinic routines, linking it to outreach platforms, and organising it within defined geographic catchment areas (DoH, 2015; NDoH, 2011; NDoH, 2018). These reforms align with global evidence demonstrating that integrated PHC systems are more effective in addressing social determinants of health and improving population health outcomes (WHO, 2008; Starfield, Shi, & Macinko, 2005).

Conceptually, integrated health promotion strengthens prevention, continuity of care, and community participation (WHO, 1986; Lawn et al., 2008). However, in practice, implementation responsibility is often fragmented across facilities, districts, and vertical programs, and health promotion competes with curative priorities in under-resourced PHC settings (Pillay & Barron, 2011; Schneider, Besada, Sanders, & Daviaud, 2018). Consequently, the extent to which health promotion is systematically embedded in PHC management, human resource allocation, and monitoring frameworks remains uncertain (NDoH, 2018; Schneider et al., 2018).

Despite strong policy commitments, limited empirical research has examined how integrated health promotion is operationalised within South African PHC facilities and community platforms (Schneider et al., 2018). Available evidence is dispersed across program evaluations, district reports, and academic studies, often focusing on localised experiences rather than system-wide integration (Pillay & Barron, 2011; Schneider et al., 2018). This fragmentation makes it difficult for policymakers and managers to determine which integration models are effective, under what conditions they perform best, and where systemic strengthening is required.

This policy brief addresses this gap by synthesising evidence on the implementation of integrated health promotion within South African PHC. It moves beyond policy intent to examine operational realities, highlighting areas of successful integration, systemic weaknesses, and implications for sustainability, equity, and overall health system performance (WHO, 2008; Schneider et al., 2018). The brief aims to support policymakers, planners, and PHC managers in translating policy commitments into accountable and sustainable implementation strategies (DoH, 2015). The analysis is guided by the following key questions:

The overall objective of this policy brief is to inform policy and practice by clarifying the current state of integrated health promotion implementation in South African PHC and identifying actionable system-level priorities to strengthen integration, accountability, and equity.

2. Policy implication

South Africa’s primary health care (PHC) policy clearly calls for integrated health promotion to improve prevention and population health and reduce health inequalities (Department of Health [DoH], 2015). In theory, this should lead to consistent health promotion in both clinics and communities, with coordinated planning, referrals, and follow-up. However, the scoping review shows that these goals are only partly achieved. The main result has been the creation of delivery platforms, especially ward-based primary health care outreach teams (WBPHCOTs), which connect clinics and communities for health promotion. These teams have helped bring health promotion activities to more households and communities, especially in underserved areas (DoH, 2018; Schneider et al., 2021). Still, the evidence shows that health promotion is not well built into daily clinic routines, which limits continuity, accountability, and sustainability. As a result, health promotion is often seen as an extra activity rather than a core PHC function, thereby reducing its long-term impact. This means health promotion may depend too much on individual clinics, local leaders, or external funding, rather than being part of PHC management, funding, and performance systems.

This policy brief addresses several related problems found in the evidence. First, there is a gap between what policies aim for and what happens in practice, with little guidance on how integration should work at the clinic and district levels. Policies explain what should be done, but not how to integrate them into daily systems. Second, workforce challenges are a major issue. Health promotion tasks are often added to already busy nurses and community health workers (CHWs), with little role protection, supervision, or feedback (Bamford et al., 2020). This makes it hard to deliver health promotion effectively, resulting in uneven quality. Third, weak monitoring and evaluation (M&E) systems limit learning and accountability. The review found little regular reporting on outcomes such as fidelity, continuity, sustainability, and cost, making it hard for decision-makers to assess value for money or plan for expansion (Proctor et al., 2011; Peters et al., 2013). Finally, equity is not well addressed. While policies focus on social factors affecting health, the evidence shows little attention to rural-urban differences, at-risk groups, or differences in capacity across provinces (Mayosi et al., 2012).

This analysis takes place in a PHC system that is changing, faces significant illness, has insufficient resources, and faces increased demand for prevention and health promotion services. South Africa’s changes to PHC, including WBPHCOTs and COPC, demonstrate a commitment to comprehensive, people-centred primary care and to aligning with global PHC principles. In this situation, integrated health promotion is necessary, not just a nice extra. However, competing medical needs, insufficient staff, and fragmented funding affect how policies are implemented. The uneven spread of information across regions also shows differences in local ability, research funding, and recordkeeping. This policy brief aims to close the gap between policy goals and practice, and to encourage better coordination.

The findings in this policy brief are based on a review conducted in accordance with set guidelines. The review brought together information from published studies, policy documents, and other sources on how integrated health promotion is carried out in South African PHC clinics and communities. A structured approach was used to collect information on how integration works, where it occurs, who is involved, the strategies used, what helps or hinders it, and the results observed. Integration was examined in four areas: how it fits into clinic routines, how staff work together, how clinics and communities interact, and how planning is done with local groups. The studies were evaluated using standard tools to assess their strengths and weaknesses. Instead of measuring how well things work, the review focused on how things are done and on identifying gaps to guide policy decisions. This approach aligns with the different types.

3. Actionable recommendations

The following recommendations are based on the review findings and align with current South African primary health care (PHC) policies. To ensure people are responsible and things work well, each recommendation has been turned into a SMART commitment, i.e., Specific, Measurable, Achievable, Relevant, and Time-bound, so those involved can track progress and ensure things get done. Where possible, suggested targets and timelines are included to encourage action and make it easier to check results. These SMART commitments aim to make integrated health promotion more regular, reliable, and fair, while recognising the limits of the available evidence.

The first actionable recommendation is to make health promotion a formal part of PHC management and performance systems. Health promotion should be officially included in PHC management structures, facility performance plans, and district planning and reporting systems. The review found that health promotion is not well integrated into routine clinic practices, with activities often carried out only when possible and with limited monitoring. Where management systems were missing, integration relied heavily on individual leaders or outside help. To help with this, health promotion measures can be added to existing groups, such as PHC facility management committees, District Health Management Teams (DHMTs), and provincial health dashboards. Adding these measures to regular meetings and reports, rather than creating new systems, would help hold people accountable without adding extra paperwork. This recommendation directly supports the National Health Promotion Policy and Strategy (2015–2019), which makes health promotion a key PHC function, and aligns with PHC reforms aimed at making the system more accountable. Most evidence on effective management systems is descriptive, and few studies have examined the effects of adding health promotion measures to regular performance systems. So, implementing this recommendation should focus on learning and improvement.

The second actionable recommendation is to clarify and strengthen staff roles, supervision, and support. There is a need to clearly define and protect the roles of health promotion within PHC teams, with organised supervision and mentoring for nurses and community health workers (CHWs). In the sources reviewed, health promotion tasks were often added to staff who were already very busy, with unclear roles and uneven supervision. This made it hard to keep things going well. This recommendation aligns with the WBPHCOT strategy, which makes CHWs a central part of community health promotion, and with COPC principles that focus on team-based care. The review did not find evidence comparing the best staffing models or the amount of supervision needed. Changes to the workforce should therefore be made step by step and adjusted to local needs.

The third actionable recommendation is to strengthen monitoring, evaluation, and learning from implementation. Measures for health promotion, such as the number of people reached, how often activities are sustained, and how long they last, should be incorporated into existing PHC monitoring and evaluation systems. The review found weak and uneven reporting of results, especially about how closely activities follow plans, how long they last, and their cost. This makes it hard to hold people responsible and to learn as a system. Regular monitoring and evaluation are needed to meet the goals of national health promotion and PHC policies, but current systems do not properly track health promotion performance. Because there are many different types of activities and settings, measures should start simple and be improved over time as more is learned.

The fourth actionable recommendation is to ensure steady funding for integrated health promotion. This means relying less on short-term outside funding by including health promotion in PHC budgets and district spending plans. Many examples depended on donor or NGO funding, raising worries about what happens when that support ends. While detailed national cost information is limited, budgets and pilot data suggest that running basic health promotion activities in PHC clinics typically require about ZAR 40,000–60,000 (about USD 2,100– 3,100) per clinic each year for training, materials, community work, and supervision. This rough estimate can help district planners and policymakers quickly see which resources are needed and make informed decisions when allocating funds. This recommendation supports broader health system goals and aligns with national commitments to improve preventive care in PHC. The review found little information on costs or value for money. So, funding decisions should be supported by focused research on how to implement them.

Lastly, ensure health promotion is fair and reaches everyone. This means giving special attention to putting integrated health promotion into practice and checking results in rural and under-resourced areas, with regular reporting on fairness. To make this happen, a simple, clear, fairness-focused key performance measure should be used, such as the percentage of rural clinics meeting set health promotion goals each quarter. Regularly tracking and reporting this measure will help focus attention and resources on the areas that need it most and show differences between regions. The evidence was mostly from certain areas, with little clear analysis of fairness or differences in how things are done. This recommendation aligns with the fairness goals in South Africa’s PHC and health promotion policies, as well as global commitments to people-centred primary care. Because there is limited information from rural areas, fairness-focused work should be combined with ongoing learning rather than strict performance targets. The recommendations, therefore, focus on practical system improvements that fit with current policy systems and local needs.

4. Conclusion/discussion

This policy brief shows that South Africa has strong policies and delivery systems for integrated health promotion in primary health care (PHC). National frameworks like the National Health Promotion Policy and Strategy, the Ward-Based Primary Health Care Outreach Team (WBPHCOT) strategy, and community-based primary care (COPC) offer a clear plan for integration across clinics and communities. However, the scoping review found that integration remains uneven, not well established, and inconsistently reviewed, limiting its impact on health and equity. The next step should be to move from setting policies to making sure they are part of everyday systems. This means including health promotion in PHC management, funding, workforce planning, and monitoring. District and facility managers need support to turn national policies into clear actions, such as defined roles, regular reporting, and accountability for integrated health promotion. Improving how implementation is learned from should be a priority, along with service delivery. Instead of starting new programs, existing PHC platforms, especially WBPHCOTs and chronic care services, should be used for ongoing improvement, with simple and practical monitoring. This would help learning while keeping extra administrative work low (Peters et al., 2013).

If integrated health promotion is properly built into the system, it can improve prevention, ongoing care, and how well services respond to social factors affecting health. If current gaps are not addressed, there is a risk of continued fragmentation, staff overload, and unfair access to health promotion, especially in rural and under-resourced areas (Mayosi et al., 2012; Schneider et al., 2021). The findings show that having delivery platforms is not enough. Without system-level integration, health promotion is at risk from changes in leadership, unstable funding, and competing clinical needs. Policymakers should see integrated health promotion as a main part of PHC, not just an extra activity.

In summary, South Africa is well-positioned to improve integrated health promotion in PHC. This will require focused action at the system level, along with targeted learning and research, to ensure policy commitments lead to consistent, fair, and lasting practice. This policy brief provides a starting point for that next step.