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

Sexual and Reproductive Health Matters (SRHM) is launching a themed issue – in partnership with the School of Public Health, University of the Western Cape, South Africa – on Queering Health Systems

19 June 2026

SALAD is a diverse collective that brings together actors with extensive experience and expertise in the DHS.

Its membership includes senior and middle-level decision-makers from all nine provinces and the national government, health policy and systems researchers from nine higher education institutions, and non-governmental partners supporting various aspects of DHS development. It is composed of a core group and a wider network of hundreds of interested stakeholders who participate in webinars and other Alliance activities.

SALADs aims to facilitate knowledge and experience exchanges that enable bottom-up learning. This learning then supports the DHS in identifying future policy and strategy needs within and across settings. It recognises the strategic importance of primary health care and its contribution to universal health coverage. Ultimately, the network strives to strengthen sub-district and district health systems, thereby improving health outcomes. For more information on the role and importance of the DHS, scroll to the bottom of this page.

To learn more about our work and outputs, read our publications organised by thematic groups below:

Thematic Groups

District Health System in South Africa

The District Health System (DHS) is the cornerstone of an equitable, primary healthcare-led system in South Africa. Here, we capture the evolution of the DHS from its early days post-1994 to the present.

Community-oriented primary care

Across South Africa, district health system leaders are imagining innovative ways to understand community health needs and integrate community voices and priorities into primary health care and public health through community-oriented primary care (COPC). Here, we explore COPC approaches implemented across South Africa.

Monitoring, evaluation, learning

To address the complex frontline realities of South African communities, the district health system must continually monitor, evaluate and learn (MEL) about what is working, what is not, and how needs are changing. Here, we explore innovative approaches to MEL across the health system.

Health financing

Quality healthcare in South Africa requires the careful management of limited financial resources. Here, we look at strategies for managing those resources in innovative ways.

Leadership

Leadership in South Africa’s DHS requires motivating and coordinating local providers while facilitating whole-of-government and whole-of-society collaboration. Here, we explore how to strengthen and conceptualise leadership without exercising traditional command-and-control managerial authority.

Quality health systems

Quality health services require complex systems and processes to work together in harmony. Here, we explore various elements of the DHS that impact the quality of health services with an emphasis on successful models from across the country.

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.

Published a special series on the DHS within the South African Medical Journal to share experiences and stimulate national debate, co-authored by government officials, front-line implementers 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 various local and international conferences.

Convened annual national retreats to review activities, reflect on purpose/identity, and chart future directions.

Organization:

The work of SALAD is carried out by various working groups, a steering committee and the secretariat. Four thematic working groups focused on leadership & management, quality improvement and learning, teaching and learning, and research explore key priorities for SALAD.

In addition, the Provincial Engagement Working Group brings together senior managers from all provinces to share best practices and discuss practical solutions relevant to the DHS. The Knowledge and Dissemination Working Group focuses on webinars, publications, and conference engagement. A small but diverse Steering Group oversees efforts across the working groups while the Secretariat, housed at the University of the Western Cape and the University of Cape Town, manages day-to-day administration and coordination.

About the DHS:

The DHS was formally established by the National Health Act of 2003 as the most decentralised public governance structure for achieving an equitable, primary health care-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.

This renewed focus is driven by:

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 reforms, which are focused on district-level structures like ‘contracting units for primary healthcare’ and district health management offices.

Multiple intersecting crises, including COVID-19, climate change, socio-economic vulnerability, and reduced budgets, 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.

Journal Articles & Reports

All
Thematic Group: Community-oriented primary care
Thematic Group: Leadership
Thematic Group: Monitoring, evaluation and learning
Thematic Group: Quality health systems
Thematic Group: The DHS in South Africa

Introductory editorial: Special series on the District Health System

By: H Schneider, T Masilela, J Mndebele, K Vallabhjee, I Petersen, L Gilson, B Engelbrecht

The changing fortunes of the DHS in South Africa (1994 – 2020): A retrospective review

By: E Whyle, T Assegaai, M Smuts, P Barron, T Masilela, K Vallabhjee, B Engelbrecht, L Gilson, H Schneider

Strengthening system leadership for the District Health System

By: L Gilson, H Schneider, B Engelbrecht, M Shung-King

The implementation of community-oriented primary care in the Cape Metro Health District: A programme evaluation

By: C Goliath, R Mash, H Mahomed

The District Health System must become a learning health system

By:

L Gilson, O Motshweneng

Community-led monitoring and the role of Ritshidze in improving the quality of primary health care in South Africa

By: K Govender, N Rambau, P Barron, B Setshogelo, K Vallabhjee, M Nyathi, H Schneider, S Xaba, N Mopofu, A Yawa

District Health System performance in South Africa: Are current monitoring systems optimal?

By: Barron P, Mahomed H, Masilela TC, Vallabhjee K, Schneider H.

Ritshidze’s community-led monitoring system as a source of information on health system responsiveness in SA

By: P Barron, B Honermann, K Vallabhjee, K Govender, H Schnedier

Improving health outcomes and quality at the subdistrict level: Evaluation of the ‘3 feet model’ in Waterberg District, Limpopo Province, South Africa

By: Schneider H, Mukinda F, Cupido J, Wessels J, Kupa P, Leboho P

All
Thematic Group: Community-oriented primary care
Thematic Group: Health financing
Thematic Group: Leadership
Thematic Group: Monitoring, evaluation and learning
Thematic Group: Quality health systems
Thematic Group: The DHS in South Africa

The DHS in South Africa: Looking back to look forward (April, 2024)

Hosted by PHASA HPSR-SIG and the South African Learning Alliance for District Health Systems (SALAD)

What are the critical issues facing the District Health System in 2026?

This April 2026 webinar identifies pressing challenges such as rapid population growth, the nursing exodus, and the financial burden of medical-legal claims.

Driving improvement: Good practice and innovation in SA’s DHS

This November 2025 webinar highlights creative ways that district teams solve complex problems with limited resources.

Beyond compliance: how can norms and standards support frontline quality improvement?

This October 2025 webinar investigates how to transition away from “malicious compliance” towards real frontline improvement across South Africa’s DHS.

Working with, and for, communities: Building trust and strengthening the DHS through community engagement

This September 2025 webinar shares real-world success stories like community-led monitoring and integrated rural development models.

Reorienting the DHS towards health promotion and wellness

This July 2025 webinar explores how the South African DHS can move away from vertical programmes towards a focus on prevention, early intervention, and people-centred care.

Innovation in leadership development – a dialogue

This May 2025 webinar explores new approaches to leadership development via workplace-based learning and the evolving role of mentorship as a mutually enriching process for mentor and mentee.

USAID Foreign Aid Freeze: Managing the funding transition during uncertain economic times

This March 2025 webinar addresses the sudden and disruptive suspension of USAID and PEPFAR funding in South Africa. Speakers report on the immediate service impacts and job losses, while identifying strategic opportunities to transition toward local ownership and integrated, person-centred care.

Beyond M&E: Leveraging learning partnerships to strengthen the DHS

This November 2024 webinar showcases collaborative partnerships between communities, academics and health managers in KZN and the Western Cape, highlighting the value of “warm data” and tacit knowledge in strengthening the system.

Capitation-based financing for primary care

This April 2024 webinar examines capitation-based financing mechanisms within the context of National Health Insurance (NHI) reforms.

Monitoring DHS performance toward UHC: How can we find a pragmatic way forward?

This August 2024 webinar examines current monitoring and evaluation (M&E) processes in the DHS, challenges and gaps, and alternative ways to strengthen M&E and support health system decision-making.

Navigating resources management at a district level

This May 2024 webinar explores district-level resource management, with a focus on the financial management capacities required within the DHS. Speakers share their work in resource management and the skills required to function effectively in financial management roles while a panel shares recommendations for effective and efficient financial management in the DHS.

SALAD Reignites Passion for the District Health System at PHASA 2025

At the April 2025 PHASA Conference, the South African Learning Alliance for the District Health System (SALAD) hosted a dynamic workshop titled “Advancing Knowledge for District Health System Strengthening.”