The South African Learning Alliance for the District Health System (SALAD) — University of the Western Cape

Imarisha: Strengthening PHC by addressing gendered workplace violence

4 June 2025

SALAD is a diverse collective that brings together actors with extensive experience and expertise in the District Health System (DHS). Its membership includes senior and middle-level decision-makers from all nine provinces and national government, health policy and systems (HPS) researchers from nine higher education institutions (HEIs), and non-governmental partners supporting various aspects of DHS development.

While there is a core group of over 30 active participants, the network reaches a wider community of over 400 people who engage through webinars or related listservs. Network governance is overseen by a SALAD Steering Group comprised of 15 members, representing provincial and national decision-makers, HEIs, and working group conveners.

Origins and Purpose: SALAD emerged from system strengthening partnerships between health policy and system researchers and decision-makers at provincial and national levels.

The idea for the network arose from a strong national interest in strengthening the DHS and from provincial-level experience with health policy and systems (HPS) research partnerships. A national workshop on the DHS in 2022, which saw overwhelming interest from decision-makers and HEIs, prompted the establishment of SALAD in May 2023 to enable ongoing exchange.

SALAD’s purpose is to support the DHS as part of wider health system strengthening, recognizing its key role as the platform for Primary Health Care (PHC) and its essential contribution to achieving universal health coverage (UHC). It aims to facilitate knowledge and experience exchange and bottom-up learning on the DHS to identify future policy and strategy needs within and across settings. Ultimately, the network strives to strengthen sub-district and district health systems, thereby contributing to improved health outcomes.

Relevance of the District Health System (DHS): The DHS was formally established by the National Health Act of 2003 as the most decentralized public governance structure for achieving an equitable, PHC-based health system. Although attention shifted to specific disease priorities after 1994, leading to fragmented interventions and underdeveloped sub-district governance, the district and sub-district are now resurfacing as important units of governance and innovation in South Africa.

The need for new paradigms of integrated service delivery, intersectoral collaboration, and a greater orientation towards health promotion, disease prevention, health, and wellness.

Renewed recognition of the importance of engaging communities, the public, patients, and frontline providers in the co-creation of health and wellness.

National Health Insurance (NHI) reforms, which are focused on district-level structures like ‘contracting units for primary healthcare’ (CUPs) and District Health Management Offices (DHMOs).

Multiple intersecting crises, including COVID-19, climate change, socio-economic vulnerability, and reduced budgets, which necessitate new ways of working within health systems.

The DHS platform is vital for implementing necessary change and generating bottom-up innovations within the health system. Learning from existing sub-national experience is crucial for strengthening the DHS to manage current crises and embed it as the foundation of PHC and UHC in South Africa. While challenges vary by district and province, requiring tailored responses, there is significant activity across settings from which all can learn.

Activities:

Since its establishment in 2023, SALAD has engaged in various activities:

Hosted a national webinar series, engaging practitioners, decision-makers, and researchers on key challenges, strategies, and innovative practices in the DHS. Eight webinars had been hosted as of end May 2025, drawing a large audience.
Published a special series on the DHS within the South African Medical Journal (SAMJ) to share experiences and stimulate national debate. Publications are jointly produced by government officials, partners, and researchers.
Co-hosted a national workshop on Community Oriented Primary Care (COPC) with the Western Cape Department of Health & Wellness.
Completed a retrospective review of DHS policy making in South Africa since 1994, including gathering and analysing over 100 documents.
Hosted dialogues and experience exchange sessions at the 2023 and 2025 Public Health Association of South Africa (PHASA) conferences.
Convened annual national retreats (~30 core members each) to review activities, reflect on purpose/identity, and chart future directions. The last retreat in May 2025 was co-hosted with the KwaZulu-Natal Department of Health and UKZN.

Organizational Arrangements:

The SALAD network is organized into several components:

Provincial Engagement Working Group (PEWG): Brings together senior managers responsible for DHS across the nine provinces.
Thematic Working Groups: Four groups focus on Leadership and Management, Quality Improvement and Learning Health Systems, Teaching and Learning, and Research.
Knowledge and Dissemination Working Groups: Focus on webinars, collaborative publications and conference engagements.
SALAD Steering Group: Comprised of 15 members representing provincial and national decision-makers, HEIs, and working group conveners, guiding and coordinating SALAD activities.
Secretariat: Housed at the University of the Western Cape (UWC) and the University of Cape Town (UCT). The secretariat supports and coordinates core and shared activities, including communication, and “holds the shared space” on a day-to-day basis.

THEMATIC GROUPS

The DHS in South Africa: Looking back to look forward

This webinar was hosted by PHASA HPSR SIG and SALAD during Global Health Week (8-12 April) as part of PHASA advocacy activities under the World Federation of Public Health Associations.

SALAD Organised Session at PHASA 2025

As part of the PHASA conference in April 2025, the South African Learning Alliance for the District Health System (SALAD) hosted a workshop titled, ‘Advancing Knowledge for District Health System Strengthening’.

Editorial Special Series on the DHS

The District Health System (DHS) is the building block of South Africa (SA)’s national health system. The DHS was formally established through the National Health Act No. 61 of 2003[1] as the most decentralised public governance structure for the achievement of an equitable health system based on primary healthcare.