Introduction
Community health workers (CHWs) have a long history in South Africa, dating back to the 1920s, when they were employed primarily as malaria assistants (van Ginneken et al., Reference van Ginneken, Lewin and Berridge2010). Initially focused on community health education and infectious disease control, their roles evolved to address other health and community needs, contributing to role complications (Tollman, Reference Tollman1994). CHWs are generally a diverse group of lay healthcare workers who mainly reside in the communities they work in but work outside the health facilities to deliver primary healthcare services and bridge the gap between health facilities and communities (Mantell et al., Reference Mantell, Masvawure, Zech, Reidy, Msukwa and Glenshaw2022). In 2004, a national policy framework was established to guide the development of the CHW programme (SA NDoH, 2004). The 2004 CHW policy included single-disease and generalist CHW functionality, with the country’s HIV and tuberculosis (TB) burden leading to expanded CHW recruitment and training (Friedman, Reference Friedman2005; Schneider and Nxumalo, Reference Schneider and Nxumalo2017).
In 2011, South Africa’s National Department of Health (SA NDoH) launched the ‘Re-engineering Primary Health Care’ (rPHC) strategy to shift towards a more community-centred model of health care. Central to this strategy was the establishment of ward-based primary health care outreach teams (WBPHCOTs), comprising generalist CHWs supervised by primary health facility-based nurses – termed Outreach Team Leaders (OTLs). Informed by the Brazil PHC approach, the PHC re-engineering strategy established the national CHW programme and the WBPHCOTs to provide comprehensive, community-level health services (Naledi et al., Reference Naledi, Barron, Schneider, Padarath and English2011; SA NDoH, 2018; Murphy et al., Reference Murphy, Moolla, Kgowedi, Mongwenyana, Mngadi, Ngcobo, Miot, Evans and Pascoe2021).
The implementation and oversight of WBPHCOTs is coordinated at the provincial level by provincial managers, senior officials within Provincial Departments of Health responsible for planning, resourcing, and monitoring primary health care programmes across their provinces. Working at the interface between national policy and district-level practice, provincial managers play a pivotal role in coordinating CHW and OTL training, allocating resources, and ensuring that national directives are translated into practice at the district, sub-district and community levels (SA NDoH, 2018).
In South Africa, the WBPHCOT operates from the national to the community level. The National Department of Health provides policy direction, guidelines, and standards. At the same time, the Provincial Departments of Health are entrusted with adapting these policies, budget and resource allocation, and implementation oversight, while the District Health Management Teams are responsible for coordinating rollout, supervision, and monitoring, with support from sub-district managers who strengthen links among clinics, outreach teams, and communities. At the facility level, primary health clinic serves as the base for the team, with a professional nurse (OTL) providing supervision and managing referrals. At the community level, WBPHCOTs, comprised of generalist CHWs and OTLs, deliver household-based healthcare services and referrals to health facilities (SA NDoH, 2018).
The WBPHCOTs serve as a bridge between communities and health facilities (van Ginneken et al., Reference van Ginneken, Lewin and Berridge2010) and work closely with health promoters, social and environmental health workers, and clinicians. The teams provide health-supportive activities, including health promotion and disease prevention. Their services cover maternal and child health, TB, HIV, and chronic disease care, treatment adherence, and retention-in-care support. They also conduct community and household profiling for psychosocial support, including referrals to social services and linkages to counselling services and the Department of Home Affairs (DHA) services where needed (Naidoo et al., Reference Naidoo, Railton, Jobson, Matlakala, Marincowitz, McIntyre, Struthers and Peters R.P.2018; Assegaai and Schneider, Reference Assegaai and Schneider2019a; Murphy et al., Reference Murphy, Moolla, Kgowedi, Mongwenyana, Mngadi, Ngcobo, Miot, Evans and Pascoe2021; Thomas et al., Reference Thomas, Buch and Pillay2021). Due to these increased responsibilities, in 2018, the minimum education entry requirement for CHWs was set at Grade 12 (SA NDOH, 2018).
Before 2018, the implementation of CHW programmes was fragmented, and there was limited documentation of practice. Furthermore, the programmes faced staff shortages, poor integration with the Department of Health (DoH), conflicting supervisory structures, and overly broad scopes of work (Naidoo et al., Reference Naidoo, Railton, Jobson, Matlakala, Marincowitz, McIntyre, Struthers and Peters R.P.2018; SA NDoH, 2018; Assegaai and Schneider, Reference Assegaai and Schneider2019a, Reference Assegaai and Schneider2019b; Murphy et al., Reference Murphy, Moolla, Kgowedi, Mongwenyana, Mngadi, Ngcobo, Miot, Evans and Pascoe2021; Mantell et al., Reference Mantell, Masvawure, Zech, Reidy, Msukwa and Glenshaw2022). In response, the NDoH, with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), introduced the outreach team (OT) programme, focusing on staffing, training, management, and monitoring and evaluation (Mantell et al., Reference Mantell, Masvawure, Zech, Reidy, Msukwa and Glenshaw2022). Key reforms included adopting a 6–10 CHWs per OTL ratio, appointing enrolled nurses as OTLs, and prioritising recruitment in underserved communities (SA NDoH, 2011; Mhlongo et al., Reference Mhlongo, Lutge and Adepeju2020; Malatji et al., Reference Malatji, Griffiths and Goudge2023). Competency-based training for CHWs and OTLs, led by the International Training and Education Center for Health (I-TECH), strengthened skills in health promotion, referrals, psychosocial support, and supervision, while facility managers were orientated to facilitate WBPHCOT integration into the health system (Mantell et al., Reference Mantell, Masvawure, Zech, Reidy, Msukwa and Glenshaw2022). To strengthen accountability, new monitoring and evaluation (M&E) tools were introduced and later digitalised through mHealth platforms to improve data quality, follow-up, and programme oversight.
A rapid appraisal of the WBPHCOTs model in National Health Insurance (NHI) pilot districts was conducted by Jinabhai et al. (Reference Jinabhai, Marcus and Chaponda2015) and identified several challenges, including operational and resource constraints, limited-service delivery, poor communication, hierarchical relationships, and inadequate interpersonal skills training. There is also a lack of literature from the perspective of provincial managers regarding the training of CHWs and OTLs in South Africa. To help address these challenges, the Human Sciences Research Council (HSRC) and the NDoH’s CHW Think Tank (CHW TT) conducted a national skills audit of provincially contracted CHWs and OTLs. The audit assessed their qualifications and CHW and OTL training needs. The findings were intended to inform training needs to guide future CHW and OTL training approaches. This paper aimed to explore the barriers and facilitators to training among CHWs and OTLs in South Africa, from the perspectives of provincial managers.
Methods
Study design and sampling
This study adopts an interpretivist stance, utilising a naturalistic inquiry approach to explore the subjective perspectives of provincial managers. Senior managers at various levels were purposively sampled across all provinces. These included master trainers, who, in their role as senior trainers, are drawn from provincial DoH staff, training institutions, or NGO/partner organisations, and are tasked with capacitating OTLs and CHWs through a cascade model. Regional Training Centre (RTC) managers are facility-based coordinators responsible for overseeing and managing training activities for CHWs and OTLs within their region. They identify training needs, coordinate training schedules, manage training activities, and maintain training records, working closely with master trainers to ensure the effective implementation of the cascade training model. Programme managers are usually part of the PHC re-engineering directorates in provinces or district health offices. In some cases, their roles are linked to HIV/AIDS, STIs, and Tuberculosis (HAST) programmes. Managers were selected in collaboration with the National Department of Health (NDoH), Provincial Departments of Health (PDoH), and the CHWTT based on their roles and experience. All participants provided informed consent. In total, 15 key informant interviews were conducted with the managers between July and August 2023. The interviews were conducted telephonically due to geographic spread (across the country) and the constant mobility of the provincial managers.
Data collection tools and procedures
A semi-structured interview guide was developed, with inputs from representatives of the NDoH, PDoH, and the CHWTT.
The key informant interviews focused on the role of provincial managers in training CHWs and OTLs. Additionally, discussions explored the availability of training, coaching, and mentorship programmes, as well as the supervision model and its frequency. The interviews were conducted in English by qualitatively trained researchers using the study semi-structured interview guide.
Prior to the study, phone numbers for provincial managers were obtained through the provincial offices. Informed consent was obtained before interviews, and all interviews were audio-recorded. Participants received a pre-interview call introducing the study, followed by an email or WhatsApp Messenger text, ethics approval letters (HSRC REC and provincial ethics approval), the study information sheet, and a consent form. The information sheet was also read out before the interview, and participants were allowed the opportunity to ask questions. Special reference was made to the voluntary participation and the maintenance of anonymity and confidentiality to minimise socially desirable bias. Verbal consent was also audio-recorded. All interviews were conducted in English and lasted approximately 30–45 minutes. Compensation for participation was not provided. The determination of data saturation was based on an iterative data collection and analysis process, with data collection continuing until no new information or themes emerged from the interviews.
Data preparation
Accredited service providers, bound by confidentiality agreements, were contacted for transcription services. Interviewers reviewed and quality-checked transcripts against their notes to ensure accuracy. Transcriptions were verbatim. Data were de-identified during transcription and translation, and the core research team conducted a final review to ensure that all identifying details were removed.
Initial coding and data analysis
The research design is centred on thematic analysis, employing a hybrid approach that incorporates both deductive and inductive coding to identify key patterns and themes within the data. A team-based coding approach was employed, with researchers overseeing the coding to improve reliability and internal validity. The study followed a phased and iterative analytical process adapted from Braun and Clarke’s guide to qualitative data analysis (Braun and Clarke, Reference Braun and Clarke2006). The initial coding guidance was provided by the researchers, utilising a hybrid approach that incorporated both deductive and inductive codes from the data to create a codebook. A subset of transcripts was coded in parallel, and the coded texts were compared to ensure consistency in their application. Coding and data analysis were facilitated using ATLAS ti.23. In Step 1, each transcript was read independently by at least two researchers to identify key points. Step 2 involved initial coding to create a preliminary list. In Step 3, the codes were reached by consensus and reviewed with colleagues. Step 4 repeated Steps 1–3 for 10–20% of transcripts. Step 5 developed a draft codebook, applied in Step 6 to the remaining transcripts. Step 7 refined the codebook through an iterative process, identifying themes and resolving differences. In Step 8, codes were grouped into themes. In Step 9 (data interpretation), we considered trustworthiness, a key criterion for evaluating the quality of qualitative research (Lincoln and Guba, Reference Lincoln and Guba1985; Ahmed, Reference Ahmed2024). To ensure trustworthiness, as outlined by Lincoln and Guba (Reference Lincoln and Guba1985), credibility was enhanced through team-based coding and reflexive discussions held throughout data collection and analysis. Dependability was supported through an iterative codebook review process, where codes were cross-checked across researchers. Confirmability was promoted by transparently documenting each analytical step. Transferability was supported through detailed participant profiles, geographic representation across eight provinces, and the use of verbatim quotes. Reflexivity was maintained through ongoing team discussions to surface and interrogate assumptions throughout the study. Qualitative data analysis is iterative, involving ongoing interpretation and refinement (Ngulube, Reference Ngulube, Mathipa and Gumbo2015). In Step 10, we report the findings.
Ethics
The study received ethical approval from the HSRC’s Research Ethics Committee (REC) (protocol REC 1/26/04/23). Ethics recertification is required annually for the duration of the project in accordance with HSRC Research Ethics Committee protocols. Provincial managers who served on the CHW TT were excluded because they were involved in reviewing and contributing to the protocol and data collection tools.
Reflexivity
The research team’s institutional affiliation with the HSRC and its established relationship with the NDoH and CHW Think Tank lent credibility and access to the data collection process. The HSRC operates with scientific independence, and this study was conducted in accordance with that principle, findings reflect the perspectives of participants rather than institutional positions. Several measures were employed to further ensure rigour. Provincial managers who served on the CHW Think Tank were excluded from participation, as they had been involved in developing the study protocol and data collection tools. A team-based coding approach was adopted, with codes cross-checked across researchers to promote consistency and reduce individual bias. Reflexive discussions were conducted throughout the data collection and analysis process to surface and interrogate assumptions. The interpretivist stance of the study is acknowledged, recognising that findings represent a co-constructed understanding of participants’ perspectives rather than an objective account. That is, findings are shaped by both participants’ accounts and the analytical lens of the research team, as is inherent in qualitative inquiry.
Study Findings
A total of 15 interviews were conducted across eight provinces between July and August 2023. Participants included provincial managers, master trainers, RTC managers, programme managers, and those in acting provincial manager positions. Representatives from the Western Cape were unavailable and were therefore excluded from the final analysis. The following table presents the three primary themes, their associated sub-themes, and the selective codes identified from the qualitative analysis of provincial manager interviews.
Themes, sub-themes and selective codes from interviews with key provincial managers
Table 1. Long description
A table with three columns and eleven rows. The columns are labeled Main theme, Sub-themes, and Selected codes. The table is divided into three main themes: Current training practices and implementation approaches, Training challenges and systemic gaps, and Strategies for strengthening CHW and OTL training. Each main theme is further divided into sub-themes with corresponding selected codes. For example, under Current training practices and implementation approaches, sub-themes include Training, coaching, and mentorship structures, Gaps in coaching and mentorship support, Foundation phase and ongoing OTL-led skills development, Internal training capacity and external support, and Reported benefits of CHW and OTL training. Each sub-theme lists specific codes related to the sub-theme.
1. Current training practices and implementation approaches
This section provides an in-depth overview of the training, coaching, and mentorship specifically designed for CHWs and OTLs, as outlined by provincial managers. It examines structured training approaches and available resources and highlights notable successes achieved through these initiatives. The analysis is organised into the following sub-themes, which capture both the structured approaches to training and the challenges, gaps, and successes that influence implementation.
1.1 Training, coaching, and mentorship structures
Provincial managers noted that many CHWs and OTLs receive their training informally, though some programmes are initiated by the NDoH. The training programme is typically divided into two phases: a foundational phase that outlines CHWs’ scope of work, and a second phase that emphasises the practical application of these skills, which are often challenging for some. As one manager explained:
‘The phase one training developed by the National Department of Health covered a lot of what we’re currently doing… Phase 2 involved practicals, which were quite difficult. We took CHWs from NGOs as they were, with or without matric, which made understanding some concepts challenging.’
In addition to the foundational training that CHWs and OTLs receive, OTLs receive additional training focused on supervisory and mentoring skills to ensure they are equipped to guide CHWs effectively. The interviews revealed that some training sessions are delivered by external trainers (often contracted through donor-or partner-funded initiatives), and participants expressed concerns about sustainability given the funds required. Managers suggested building internal training capacity by using departmental staff, particularly at the district level. This was seen as a more sustainable approach that allows ongoing adaptation of content while maintaining programme consistency and ownership.
1.2 Gaps in coaching and mentorship support
Formal coaching or mentorship programmes were noted to be limited in scope and availability. Most provincial managers are not directly involved in the training, instead, line managers manage training needs, while RTC managers coordinate and oversee training, identifying training needs, managing training activities, ensuring that they receive training, and maintaining training records for CHWs and OTLs. The cascade model of training was referenced during interviews:
‘The CHWs are trained through the foundation phase learning, which is developed by the National Department of Health and a partner… all Community Health Care workers are trained on that programme by the Outreach Team Leaders. The Outreach Team Leaders are trained by Master Trainers, and Master Trainers are trained through the Regional Training Centre. The Master Trainers are essentially sub-district coordinators.’
RTC managers thus coordinate training needs, with Mater Trainers delivering training to OTLs, which then filters down to CHWs.
1.3 Foundation phase and on-going OTL-led skills development
Managers describe the foundation phase, developed by NDoH and partners, as the initial training stage, followed by OTL-led skills development, which includes specialised training in areas like HIV testing and TB screening. Other specific training includes facility-based training, which covers malaria, NCDs, COVID-19, maternal and child health, and emergency management.
‘…we do have different training categories based on the services that are rendered, for instance in malaria-prone areas we do give them the training, we talk about malaria, the screening services that they have got to conduct to the testing that they need to conduct and to all the home-based care.’
1.4 Internal training capacity and external support
Most training is conducted internally within health facilities, which organise and deliver it using their own staff, structures, and resources. They are often assisted by academic institutions to enhance the quality and availability of educational resources. A commonly used approach is the decentralised cascade model, where OTLs serve as on-the-job trainers for CHWs. This in-house method helps maintain consistency and relevance in the training material. However, this approach has limitations. While OTLs are well-trained and skilled in clinical practices, many have not received training in managing and supervising CHWs.
To address these challenges, external partners sometimes play a role in the training ecosystem. They provide supervisory training for OTLs, focusing on essential management skills such as leave management and reporting – the latter being crucial for ensuring that CHWs can document their activities accurately and share important data with their clinics.
‘… we have got a manager that is responsible for that…that can give you an appropriate to say from day 1 to day 2 this is what we have done …you must know that some of them had been received as NPOs for training as community health care workers, whether it will be through the RTCs and they were trained there for formal training and they were given certificates some of them, depending on the appointed service provider and the capacity that they had and also they were extra funded courses that were given to them…’
Overall, while the decentralised cascade model promotes self-sufficiency in training, continuous development and support for OTLs are necessary to enhance the quality of training delivered to CHWs.
1.5 Reported benefits of CHW and OTL training
Despite the challenges, provincial managers acknowledged notable successes in CHW training. CHW training was described as beneficial, encompassing relevant topics and leading to improvements in areas such as ART programme delivery, health education, and the accurate documentation of patient and service data. Improved communication between CHWs and OTLs was identified as a key success, with WhatsApp facilitating updates on medicines and health developments, as noted in the following quote.
‘We established a WhatsApp group for peer educators, allowing them to communicate directly about issues, such as developments in injectable antiretroviral drugs. This helped create an open line of communication between the province, district, and CHWs at the facility level.’
2. Training challenges and systemic gaps
Provincial managers highlighted key challenges in the training process for CHWs and OTLs, mainly related to training resources, varying literacy and qualifications, and a shortage of trainers.
2.1 Insufficient training tools and resources
All provinces reported receiving training manuals and job aids, but there were significant issues with the availability of sufficient printed materials for all who required them. Trainees often had to print materials themselves or access updated content via the South African National DoH Knowledge Hub (SA NDoH, 2025), an online learning and information management platform established by the National Department of Health to support continuous professional development. While the Knowledge Hub provides a centralised space for sharing training resources, policy documents, and updates, access was sometimes limited by poor internet connectivity, lack of data, and limited digital literacy among some CHWs and OTLs. These challenges made it difficult for some users to regularly access or download the required training content.
‘We have a health promotion/education flip file, which is good, but SOPs are not well integrated. There should be a unified curriculum and manual to ensure consistent training across provinces.’
Concerns were also raised about outdated manuals, a lack of understanding of Standard Operating Procedures (SOPs), and inconsistent monitoring assessments. Participants noted that while some provinces had updated materials aligned with the latest national guidelines, others continued to rely on older versions, creating inconsistencies in the content and quality of CHW training. The lack of integration between training manuals, SOPs, and job aides was seen as undermining the uniform implementation of the WBPHCOT programme. Respondents emphasised the need for a uniform nationally endorsed curriculum, encompassing all the above-mentioned training, and up-to-date SOPs accessible through the Knowledge Hub and other platforms to promote standardisation, improve supervision, and enhance the quality of service delivery across provinces.
2.2 Educational gaps and literacy barriers
The managers indicated that training CHWs and OTLs together presents a significant challenge, primarily due to the literacy levels and diverse levels of education. A substantial proportion of CHWs have not completed their matric certificate, which is a critical educational milestone. This often means there is limited foundational knowledge, which complicates their ability to understand and engage with more advanced or intricate topics presented during training sessions.
‘What becomes difficult is the varying educational backgrounds. Some CHWs may not have matric, and others may have only completed grade 5 or 6. This affects their ability to grasp the training content, especially in the second phase.’
While this approach of training CHWs and OTLs together can promote teamwork and shared learning, it also highlights the disparity between the two groups. OTLs are typically qualified and experienced health professionals, often registered nurses, whereas CHWs come from less formal educational backgrounds.
‘There is a vast difference in academic capabilities between CHWs and OTLs, which makes it difficult to develop a curriculum that suits both groups.’
These differences in educational attainment and professional experience can lead to gaps in understanding and skills, making it challenging to design a curriculum that simultaneously meets the learning needs of both cadres.
2.3 Barriers to effective in-service mentorship
In-service mentorship was described as inconsistent and constrained by time and capacity. As one participant mentioned:
‘…we don’t mentor them because, though they are attached to a facility, the OPM (Operational Manager) does not have enough time. The OPM has a conflict of priorities, and there is no structured position for mentorship…’
2.4 Shortage of trainers and logistical challenges
A key barrier to effective training is the shortage of master trainers, as reported by a substantial proportion of provincial managers.
‘The province only has around 5 master trainers, and if you look at a group of 2500 community health workers that’s too little to be able to make the progress you want…’
A limited number of trainers also causes logistical problems, with some responsible for multiple sub-districts, making it difficult to provide adequate support and leading to challenges in maintaining quality and scale.
‘One trainer must support 8 sub-districts, which creates difficulties for mentoring, especially with transport issues.’
2.5 Shortage of basic training equipment and support material
Training materials, including stationery and equipment, are often in short supply.
‘Stationery is not enough for us and them… each one should have some basic equipment with them…and then they must have your thermometer, your own BP machine, and your scale…So, they need to have the basic equipment and the supplies…’
These tools are essential but are often insufficient. In addition, funds for training workshops are constrained, and meals are often not provided.
3. Strategies for strengthening CHW and OTL training
Provincial managers suggested various strategies to improve the training process.
3.1 Strengthening mentorship and leadership for OTLs
A major recommendation was to provide enhanced training for OTLs, especially in mentoring and coaching as a team leader, areas not covered in their initial nursing training and in training as members of the WBPHCOTs. OTLs also need support in leadership and communication skills.
‘…communication skills are very important for us to bridge that gap…it probably gets even worse with the mentoring and coaching…but the challenge that we have sometimes is that OTL might not be capacitated or educated (to lead a team)…’
3.2 Targeted training as a means of enhancing job satisfaction and ownership
There is a need to address specific training areas for CHWs and OTLs. While OTLs have clinical skills, they may lack leadership abilities, while CHWs face challenges due to limited training. Some suggested that challenges related to job satisfaction and retention are determined by how OTLs are appointed. Nurses who volunteer to serve as OTLs were often described as more motivated, proactive, and committed to mentoring and supporting CHWs, viewing the role as an opportunity for professional growth and community impact. In contrast, those assigned the role involuntarily tended to show lower levels of engagement and ownership, often perceiving the position as an additional burden rather than an extension of their professional responsibilities.
‘…the mere fact that they are not being appointed but assigned (non-voluntarily), some you find that they lose interest, then they go back to the facility when they encounter challenges, and they (facility) have got to appoint to assign new ones’.
Poor commitment to the OTL role sometimes led to higher turnover among OTLs, inconsistent supervision, and interruptions in CHW support and team performance. Participants highlighted the need for clearer selection criteria, role recognition, and incentives to ensure that OTL appointments attract motivated candidates who are prepared and supported to fulfil their supervisory functions effectively.
3.3 Scaling up trainer capacity and frequency of training
To meet training demands, an increase in the number of trainers and training sessions was suggested. The sustainability of external trainers was also questioned, with a suggestion that using in-house trainers would be more realistic for building internal capacity.
‘…sometimes there’s an external budget constraint…so we’re trying to have an internal capacity so that it (training) can be an ongoing thing. So, we know in 6 months it might change course a little bit but it’s the same people and mechanism…we should use internal capacity maybe at the district level to train our Outreach Team Leaders’
3.4 Budgetary constraints and the need for a dedicated training budget
Insufficient funding affects various aspects of training, including funds for transportation organised by facilities. While some funding is set aside to cover training essentials, including transport and its associated costs, it remains a challenge.
‘We don’t even have specific funding set aside for training and developments of the CHWs…’
‘If you don’t have the transport that is going to bring the people to the training venue, it becomes critical…so transport does become a barrier to their learning’
Nevertheless, participants discussed a dedicated training budget that would cover all components of in-person and online training, including transport and equipment.
‘…we don’t even have specific funding that is set aside for those training and developments of the CHW. We don’t even have special funding that is set aside for the OTL, they’re all squashed within what is affordable and doable at a particular point in time’
‘Some CHWs have challenges with the devices, so the phones to log in so they probably need somebody who can log them into a system to do that…some of them are not equipped to manage the online training that we expect them to do’
3.5 Revising and translating training materials
Regular updates to training materials are essential to keep them relevant. While competency in HIV and TB is highlighted, the managers indicated that CHWs should acquire additional training in other public health areas.
‘…areas that are not yet that much explored now it’s around your maternal health, your post-natal health, child’s health, and your NCDs…in those areas we still have to expand and assist them to improve their skills and their competency in those areas’
Additionally, simple translations of manuals into local languages are important, especially because CHWs have varying literacy levels and abilities.
Participants also discussed improving training manuals as another way to enhance training.
‘Our manuals are also sorted out at the national level, we don’t develop them in the province. So, you’d find that sometimes when you conduct these trainings, the scenarios that would still be referred to in the manual when you look at the practical part of it it’s no longer a relevant scenario… We need to update …those are challenges that affect the quality of training …’
This highlights the varying perceptions among participants: some express a need for standardised training, while others see the development of national-level materials as problematic and not tailored to the province.
3.6 Practical hands-on training
The managers recommended incorporating more practical learning into training programmes to ensure that CHWs and OTLs can apply the knowledge gained in training to real-life settings. The improvement of tools for practical learning during training was also regarded as an important stepping stone to delivering an improved training service.
‘…the use of the tools that they are given … they don’t give that much time into the practical part you are trained on. It’s just sort of theory, but I think it needs another time where we can do more practice to make sure that they can apply knowledge learned when it comes to practice’
Discussion
CHWs and OTLs are essential to improving healthcare access and outcomes in South Africa. While some progress has been made in establishing CHW training and roles, several systemic and operational barriers hinder their effectiveness and impact. Understanding the challenges and facilitators that enable success is crucial for improving healthcare in underserved communities. Our study found that while the current CHW training structure provides a standardised foundation, it lacks a robust, formal mentorship framework for reinforcing practical skills post-training. Without structured coaching, CHWs may struggle to translate theoretical knowledge into effective practice, potentially compromising the quality of their service.
Although OTLs are linked to healthcare facilities, mentorship support from OPMs remains inconsistent. OPMs are often unavailable to provide hands-on, structured mentorship because of competing priorities. The Supportive Supervision and Mentoring (SSM) strategy used by the African Health Initiative (AHI) to enhance primary health care quality and effectiveness in Ethiopia, Uganda, Ghana, and Mozambique is an example of an approach that shows that context-specific, integrated monitoring approaches significantly improve the knowledge, skills, and motivation of primary health care workers (African Health Initiative Partnership Collaborative, 2022). Establishing a similarly formalised mentorship framework in South Africa (with dedicated personnel for in-service training) could improve supervision, on-site mentoring, joint problem-solving, and data-driven feedback. This approach improves both OTL and CHW performance and retention.
The phased training approach developed by NDoH has demonstrated utility in equipping CHWs with essential skills. Phase one focuses on theoretical knowledge, while phase two emphasises practical skills application. This phased approach to training is also currently being implemented in various African countries to enhance CHWs’ competencies, with good outcomes. A notable example of a large-scale African CHW initiative is the ‘Resilient and Empowered African Community Health’ (REACH) programme, a collaboration between the International Federation of Red Cross and Red Crescent Societies (IFRC) and the Africa Centres for Disease Control and Prevention (Africa CDC), aimed at training and engaging two million CHWs across Africa (Idriss-Wheeler et al., Reference Idriss-Wheeler, Ormel, Assefa, Rab, Angelakis, Yaya and Sohani2024). Phased and Work-Integrated Learning (WIL) approaches facilitate structured skills development and allow for continuous assessment and adaptation to the evolving needs of the workforce. This reduces cognitive overload while enhancing knowledge retention (Schneider and Nxumalo, Reference Schneider and Nxumalo2017) and supports mentorship and peer learning, fostering a sustainable workforce. Additionally, phased training aligns with resource constraints by spreading costs over time, ensuring steady and cost-effective capacity-building (Mantell et al., Reference Mantell, Masvawure, Zech, Reidy, Msukwa and Glenshaw2022; Motsieloa, Reference Motsieloa2022). To enhance CHW competency, training programmes should emphasise practical learning. Increased opportunities for hands-on practice would reinforce theoretical knowledge and improve field application. Strengthening the integration of practical learning components within training curricula could lead to more confident and capable CHWs. Formal mentorship programmes with clear roles should be introduced for OTLs requiring additional training in leadership and communication.
The study also found noticeable successes in the training and communication systems within the CHW and OTL framework. For example, the use of WhatsApp groups enables real-time peer-to-peer communication and rapid dissemination of critical updates, such as developments in treatment protocols. Other digital communication strategies, such as the MomConnect platform, have enabled CHWs to provide timely health updates to pregnant women and report challenges directly to the supervisors (Barron et al., Reference Barron, Peter, LeFevre, Sebidi, Bekker, Allen, Parsons, Benjamin and Pillay2018). Similar platforms, such as Liberia’s mHero platform, which has facilitated two-way communication between CHWs and health officials, provided motivational messages, training updates, and emergency alerts, led to increased workforce retention and rapid response to new and recurrent infectious diseases (IntraHealth International, 2020).
Training challenges and shortcomings
Several systemic and structural challenges continue to undermine training implementation, including limited funds for training, transport issues, a lack of materials and training equipment, and the need to ensure the attendance of all CWs and OTLs who require training. A key challenge is the diverse educational backgrounds of CHWs, many of whom lack formal school education. This variation in education levels and comprehension complicates curriculum delivery and affects some CHWs’ ability to engage meaningfully during training. The differences in academic capabilities between CHWs and OTLs require training programmes that effectively cater to both groups. Providing training to both cadres simultaneously presents challenges, given that many CHWs transition from NGO-based employment without standardised educational criteria. Therefore, separate training should focus on the specific roles played, making it more targeted and supportive.
Inconsistencies in the availability of training materials and guidelines can significantly hinder effective learning among CHWs. While health promotion materials are available, the absence of well-integrated SOPs limits uniformity across provinces. Implementing a training curriculum and standardised manuals in appropriate languages could enhance consistency. A report by the Washington State Department of Health found that inconsistent resources pose challenges to skill enhancement among CHWs (Washington State Department of Health, 2019). This is likely to be the case in the South African setting. To address diverse literacy and comprehension levels, training materials should be adapted to include multilingual resources and simplified content, ensuring accessibility for all CHWs and those with limited prior clinical experience. Translating materials into local languages and dialects and incorporating visual aids can further support comprehension. Improved standardisation of training manuals and job aids across provinces would promote targeted focus, coherence, and quality in training outcomes, ensuring that appropriate knowledge and skills are transferred.
A limited number of master trainers is another constraint: only five trainers provide training (to OTLs), benefiting up to 2,500 CHWs in some provinces, which leads to slow progress and limited opportunities for effective mentorship. This is exacerbated by logistical challenges, particularly transport constraints. A decentralised, adequately supported technology-driven, and peer-based training model (like Ethiopia’s Health Extension Programme (HEP), which trains regional trainers to train district-level trainers), could address this gap (Medhanyie et al., Reference Medhanyie, Spigt, Dinant and Blanco2012). Similarly, India’s National Rural Health Mission (NRHM) implemented e-learning modules and virtual classrooms for Accredited Social Health Activists (ASHAs), enabling flexible training with reduced dependence on in-person trainers (Bashingwa et al., Reference Bashingwa, Shah, Mohan, Scott, Chamberlain, Mulder, Rahul, Arora, Chakraborty, Ummer, Ved and LeFevre2021). These approaches could be complemented by couriering printed materials for training before training sessions.
Financial constraints further exacerbate training challenges. The lack of dedicated funding for transportation affects attendance at training workshops. Ensuring that an adequate dedicated budget is allocated for training and transport could significantly improve participation and overall programme effectiveness. Linkage to resources such as the Project ECHO model, used in multiple countries, could also connect CHWs and primary healthcare workers with specialists via virtual mentoring sessions, thereby enhancing clinical knowledge without requiring travel (Arora et al., Reference Arora, Kalishman, Thornton, Komaramy, Katzman, Struminger, Rayburn and Bradford2017). However, this would require adequate data connectivity and device access, which participants identified as significant barriers for some CHWs. Additionally, dedicated and adequate financial allocation would improve the efficiency of the training and provide sufficient trainers and training materials.
Access to training materials, including stationery and basic equipment, remains a critical concern, as sufficient resources are needed to engage effectively with training content (D’Ambruoso et al., Reference D’Ambruoso, Abruquah, Mabetha, van der Merwe, Goosen, Sigudla and Witter2023; Stansert Katzen et al., Reference Stansert Katzen, Reid, Laurenzi and Tomlinson2024). Addressing this gap would require better resource allocation and logistical planning to ensure that all CHWs are adequately equipped for their roles (Ngcobo et al., Reference Ngcobo, Scheepers, Mbatha, Grobler and Rossouw2022). Other studies have shown that CHWs often face logistical challenges, such as a lack of personal protective equipment (PPE), unavailable transport, and missing essential tools, which impact their ability to provide quality healthcare (D’Ambruoso et al., Reference D’Ambruoso, Abruquah, Mabetha, van der Merwe, Goosen, Sigudla and Witter2023). Strengthening supervision, increasing funding, and ensuring access to adequate resources are necessary to enhance CHW effectiveness (Stansert Katzen et al., Reference Stansert Katzen, Reid, Laurenzi and Tomlinson2024). Expanding training capacity through district-level trainers and digital platforms with adequate connectivity and access support could reduce reliance on a limited number of master trainers and extend support to more CHWs and OTLs. However, the absence of a dedicated training budget undermines the sustainability of these efforts. Investment in infrastructure, materials, and fair compensation for trainers is essential to strengthen programme effectiveness. Coupling increased training capacity with secure funding will enhance the long-term impact of CHW and OTL capacity-building initiatives. Additionally, leveraging existing cost-effective structures, such as the decentralised cascade model and the NDoH Knowledge Hub, for centralised, standardised content distribution can maximise resource utilisation. Utilising digital tools such as virtual mentoring (e.g., Project ECHO) and real-time communication platforms (like WhatsApp) further reduces logistical costs associated with travel and printed materials.
Strategies to improve training
Training for supervisory roles primarily focuses on administrative competencies (such as leave management and human resource logistics) while neglecting mentorship and coaching capabilities. OTLs should be trained using a variety of approaches based on their existing knowledge and expertise. For example, the training manual developed by the Earth Institute at Columbia University (Earth Institute at Columbia University, 2013) in the US highlights the importance of multi-approach training, including written exercises, group activities, discussions, role-plays, case studies, and hands-on practice. Investing in OTL training programmes that focus on leadership, instructional techniques, and a sustained, fully resourced mentorship framework could strengthen their capacity to support CHWs in the field. Such training practices would foster ongoing mentorship and enhance leadership, both of which would be important for OTLs as they navigate frontline challenges.
Limitations
Several limitations of this study should be acknowledged. First, representatives from the Western Cape were unable to participate during the data collection period, which limits the geographic representativeness of the findings across all nine provinces. Second, interviews were conducted telephonically due to the geographic spread of participants and their constant mobility, which may have affected rapport between interviewers and participants and limited the depth of responses compared to face-to-face interviews. Third, provincial managers who served on the CHW Think Tank were excluded from participation, as they had been involved in developing the study protocol and data collection tools; however, their exclusion may have removed some of the most knowledgeable informants on CHW and OTL training. Fourth, the study captures only the perspectives of provincial managers and does not include the voices of CHWs and OTLs themselves, which may present an incomplete picture of training experiences at the community level. Fifth, despite measures taken to minimise socially desirable responding, including emphasising voluntary participation and confidentiality, the possibility of social desirability bias cannot be entirely excluded. Finally, the use of a hybrid thematic analysis approach, while transparent and well-suited to the study’s aims, may have constrained the emergence of unanticipated themes that a purely inductive approach might have surfaced.
Conclusion
This study highlights that while South Africa has established a structured training platform for CHWs and OTLs, gaps in mentorship, supervision, training resources, and support systems continue to limit the translation of training into effective community-based practice. Addressing these issues requires a multifaceted approach that incorporates enhanced mentorship, increased training capacity, dedicated funding, and improved training resources. Policymakers should prioritise the implementation of evidence-based mentorship and training models, including structured supportive supervision, differentiated training pathways, and sustained investment in workforce development, to improve CHW performance, retention, and the quality of community health services.
Data availability statement
Anonymised transcripts and the coding framework created for data analysis are available for the purposes of reproducibility in line with the data sharing policies of the Human Sciences Research Council (HSRC). Requests can be directed to the corresponding author.
Acknowledgements
We are grateful to the National Department of Health (NDoH) for the opportunity to undertake this project and the members of the National Department of Health Community Health Worker Think Tank (NDoH CHWTT) led by the Deputy Director-General (DDG) Primary Health Care, Ms JR Hunter, who provided input and support to the research team in developing the project tools and facilitating implementation. We would also like to thank all the participants, without whom this study would not be possible.
Author contributions
Sizulu Moyo – conception or design of the work; Natisha Dukhi, Zainonisa Petersen and Allanise Cloete – analysis and interpretation of study data; Sizulu Moyo, Natisha Dukhi, Zainonisa Petersen, Allanise Cloete, Yolande Lisette Shean, Shandir Ramlagan, Adlai Davids, Rindidzani Magobo drafted the paper, critically revised the content aimed at developing valuable intellectual content. All authors confirmed final approval of the version to be published.
Funding statement
This work was supported by the Johnson and Johnson Foundation through the Health Systems Trust
Competing interests
The authors declare that they have no competing interests.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation (protocol REC 1/26/04/23) and with the Helsinki Declaration of 1975, as revised in 2008. Ethics recertification is required annually for the duration of the project in accordance with HSRC Research Ethics Committee protocols. All participation was voluntary, and participants provided written informed consent before their involvement. Confidentiality and anonymity were ensured throughout the study.
Use of artificial intelligence (AI) tools
No AI tools were used during the data collection and analysis phase. Grammarly was used for spelling and grammar refinement.
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