A qualitative study of provincial managers’ perspectives on community health worker (CHW) and outreach team leader (OTL) training in South Africa: practices, systemic challenges, and strategic recommendations for strengthening primary health care

This paper explores barriers and facilitators to training of community health workers (CHWs) and outreach team leaders (OTLs) in South Africa, from the perspectives of provincial managers. Ward-based Primary Health Care Outreach Teams (WBPHCOTs), comprised of generalist CHWs, supervised by OTLs (nurses), are a central pillar of South Africa’s primary health care system, increasingly playing a critical role in extending services to underserved communities. As their responsibilities expand, effective and well-resourced training is essential; however, training approaches remain uneven across provinces. Between July and August 2023, a descriptive exploratory qualitative study was conducted among 15 purposively selected provincial managers whose roles involved interfacing/engaging with CHW responsibilities across the country’s eight provinces. Telephone interviews were audio-recorded, transcribed verbatim and thematically analysed using Atlas.ti 23. Three key themes emerged: (i) current training practices and implementation approaches; (ii) training challenges and systemic gaps; and (iii) strategies for strengthening CHW and OTL training. Training is undermined by varying educational backgrounds and literacy barriers between CHWs and OTLs, a shortage of master trainers, and systemic constraints, particularly the absence of a dedicated training budget, inaccessible updated training materials, and logistical issues, including limited internet access and transport. Findings highlight the need for standardised, updated training materials, practical skills training, and translation of resources into local languages. Formal mentorship programmes, leadership and communication training for OTLs, and a dedicated training budget would alleviate systemic constraints. Increasing master trainers and partnerships with external organisations, to transfer skills and build internal capacity can strengthen support for CHWs and OTLs, improving service delivery and health system outcomes.