Global Health Promotion

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Health promotion capacity building in South Africa

Jane Wills and Michael Rudolph
Global Health Promotion 2010 17: 29
DOI: 10.1177/1757975910375167

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 Original Article

Health promotion capacity building in South Africa

Jane Wills1 and Michael Rudolph2

Abstract
Health promotion in South Africa is in its early stages and while there is some institutional develop-
ment and capacity building for managers, there has been relative disregard and lack of attention of
the wider health promotion workforce who carry out community-based health promotion activities.
This article describes one regional education and training programme for health promoters as well as
the limited available evidence on the impact of the project on learners and organizations. Marked dif-
ferences before and after the implementation of the training activities were reported in relation to
behaviour change communication and project planning, in addition to self-reported positive change
in knowledge, confidence and a high level of participant satisfaction. Investment in individual skills
development needs to be accompanied by wider workforce development with organizational/
institutional development and recognised competencies frameworks. (Global Health Promotion,
2010; 17(3): pp. 29–34)

Keywords: capacity building, health promoters, health promotion, South Africa, workforce development

Introduction organizations (NGOs) such as Soul City and

In many countries health promotion faces challenges
including a lack of clarity about associated roles, lines
of accountability and gaps in competency, skills and
training. In South Africa, health promotion is a
relatively new concept, but widely supported. The
1997 White Paper on the Transformation of the
Health Services (1) argues for the role of health
promotion and health education to ‘assist people to
gain and maintain good health through promoting a
combination of educational and environmental sup-
ports, which will influence people’s actions and living
conditions’. There is a structure for health promotion
delivery: the National Department of Health has a
directorate of health promotion and each of nine
provincial governments has health promotion
co-ordinators. There are several non-governmental
Lovelife providing health promotion services. The
health-promoting schools programme is fairly well
supported and legislation on tobacco control has
been successfully implemented. However, according
to Onya (2), health promotion services ‘have not
received priority attention’ from the Department of
Health and the national health promotion strategy
has been in draft for several years. Programmes and
activities are in most cases, planned and managed by
health care professionals whose concept of health
does not derive from the theoretical base or principles
of health promotion and professional barriers and
rivalries impede development (3). In common with
many other African countries, health promotion pro-
grammes are also compromised by the rise in the
health sector of donor-funded programmes focused
on therapeutic interventions for specific diseases such

1. Correspondence to: Jane Wills, London South Bank University, Institute of Primary care and Public Health, Borough
Road London, London SE1 0AA, UK. (willsj@lsbu.ac.uk)
2. University of Witwatersrand, Johannesburg, South Africa
(This manuscript was submitted on September 16, 2009. Following blind peer review, it was accepted for publication
on January 26, 2010)

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30 J. Wills and M. Rudolph

•
•
Parenting education, health advice and information for new and potential parents

•
Support and advice for breastfeeding mothers and women at risk of transmission of HIV

•
Promoting child health and immunization

•
Advice on contraception and termination of pregnancy

•
Working with groups who have particular needs like children with physical and mental disabilities
Working with local communities to help them identify and address their own health needs, for example accident

•
prevention and hygiene practices in the home

•
Developing support groups in communities, for example to help people with TB

•
Supervising medication programmes, for example TB

•
Child and Adolescent health programmes: healthy life-style promotion, HIV/AIDS, alcohol, drugs, smoking

•
Community motivation to achieve high coverage in immunization programmes

•
Working with schools to implement a Healthy Schools programme
Organizing health promotion programmes for the users of the primary care centre

Figure 1. Examples of health promotion by health promoters

as HIV/AIDS, TB and malaria and individualistic
programmes focused on behavioural change (4,5).
A report on the Status of Health Promotion in
South Africa in 2004 (6) described in detail the nature
of the workforce painting a picture of a stable, pre-
dominantly female, but largely untrained workforce,
50% of health promoters having only a matriculation
certificate. A variety of job titles exist but there is a
similarity in roles, most health promoters working
from primary health care clinics with their main
activity delivering talks in the clinic to waiting
patients, or in villages on chronic disease manage-
ment, disease prevention and lifestyle change. The
focus of the talks is governed by a ‘health promotion
calendar’ that suggests a topic for the week or month.
For example, each week of February 2007 in Western
Cape thus focused in turn on sexually transmitted
infections and condom awareness, heart health, preg-
nancy education and teen suicide.
While the infrastructure exists for health promotion
in South Africa, the human resource development pro-
gramme has struggled. Many countries have recently
begun to address the regulation of the health promo-
tion workforce specifying competencies for practice
and standards for education and training for specialists
(7) and there are attempts to establish an international
consensus on core competencies (8). Training can then
seek to enhance, develop and strengthen these compe-
tencies to perform tasks that facilitate health develop-
ment objectives. Onya describes the frustrating and
slow process of developing competencies and creden-
tializing health promotion in South Africa (9). While
health promotion has been regarded as a specific
specialty and a Standards Generating Board was pro-
posed 10 years ago to develop qualifications and unit
standards and establish a means whereby short courses
could be accredited and contribute towards a qualifi-
cation for first and second level learners, little progress
has been made.
In the absence of occupational standards or com-
petence, the tasks expected of health promoters
indicate a need for training in interpersonal commu-
nication and simple counselling skills, and the
design and implementation of simple health promo-
tion activities for use in the community in relation
to healthy lifestyles, the management of conditions,
hygiene and control of communicable diseases.
Figure 1 illustrates the range of work expected to be
carried out by health promoters in South Africa.
The province of Gauteng (population of approxi-
mately 12m people) has approximately 230 health
promoters (HPs). A national report (6) concluded
that the quality of health promotion services
needed to be improved through formal training and
education, and the implementation of professional
standards. The National Directorate therefore rec-
ommended in 2004 that health promoters should
not only have a matriculation certificate to practise
in the field of health promotion but also a post-
matriculation qualification. This proposal is some
way off coming into effect. In Gauteng just over
20% of health promoters currently have post-
matriculation qualifications.
This article reports on a training programme
to develop the capacity and capability of health
promoters in the Gauteng province of South Africa.

IUHPE – Global Health Promotion Vol.17, No. 3 2010

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 Original Article
Background
In 2005, Gauteng provincial Department of Health
requested the University of Witwatersrand (Wits) to
provide an entry-level course in health promotion
for 230 health promoters. Wits University’s strategy
is to produce high quality graduates who are pre-
pared and ready to actively participate and make a
difference in their communities. Few health promot-
ers have the education level to meet university
degree requirements although 75% of those in
Gauteng have a matriculation certificate, which met
university enrolment procedures. Satisfactory com-
pletion of the course would lead to a Certificate of
Competency. Gauteng Department of Health paid
the student fees (currently R14,234 or 1,164 GBP)
from their bursary fund. Students were given time
off work for two 7-day modules each year and a
day’s training between each module.
The objectives of the course were to raise aware-
ness and understanding of the concepts of health
promotion and its value within primary health care,
to improve and enhance skills in relation to consult-
ing, training/educating and motivating individuals,
to enable the health promoters to initiate and
sustain health promotion programmes and to
monitor and evaluate individual and community
health and health promotion programmes.
The course comprised four modules delivered in
7-day blocks (240 hours) over two years – Health
Promotion Principles and Practice; Strategies and
Methods including helping people to make and
maintain informed health choices, empowering
and mobilizing local communities for health,
and developing health promotion programmes;
Monitoring, Evaluation and Evidence for health
promotion including theory-based planning and
greater use of evidence to guide interventions; and,
Management and Leadership including project
management, report writing, monitoring and audit
and conflict management and negotiation skills. The
module content was based on the expressed needs of
the provincial Department of Health, the learners’
descriptions of their work and assessment of their
own health promotion skills and competencies
for health promotion at entry-level in the UK
(www.skillsforhealth.org.uk). Each module is equiv-
alent to 60 SAQA (South African Qualification
Association) credits at levels 5 and 6. Each module
was assessed by a short answer exam paper (50%),
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31
to comply with the university’s assessment regula-
tions, and a work-based project, such as developing
and describing an educational session (50%).
By June 2009, 125 health promoters will have
attended and completed the course, 71 have been
awarded their four Certificates of Competence and
the sixth group of 32 commence their new course in
July 2009.
Methodology
The aim of the evaluation study was to explore
the experiences of the first cohort of trained health
promoters and to use the findings to determine
whether and how the training programme contributes
to capacity building.
A qualitative methodology using semi-structured
interviews was used in order to capture the subtle
interpretations of the health promoter role and
the impact of training. Twenty health promoters
from a cohort of 31 students consented
to be interviewed. These informants comprised
14 women and 6 men with a length of time in
post from 5 to 20 years and all were in senior
positions and possessed a matriculation certifi-
cate. Interviews were conducted in English as the
students reached the end of their course in 2007.
Because the participants would be discussing
issues related to the development of the course
before its completion, to develop trust an external
evaluator was employed to conduct the inter-
views. Participation was optional and the learners
were informed that the purpose of the data collec-
tion was to evaluate the usefulness of the course
to inform future developments. Kirkpatrick’s (10)
evaluation framework was used to inform the
interview guide focusing on the learner reaction
to the course; perceived learning and acquisition
of knowledge and skills; their reported subse-
quent application of new knowledge; and its
impact on the organization and their role in the
organization. The interviews were recorded and
transcribed in full and then analysed by two
researchers using thematic coding based on the
interview topic guide to develop categories of
analysis and to identify similarities and differences
amongst the learners. All of the data were fully
anonymized to protect the identity of the partici-
pants as both students and employees they might
otherwise feel constrained and not talk freely.
IUHPE – Global Health Promotion Vol.17, No. 3 2010
32 J. Wills and M. Rudolph
Findings
The initial audit revealed high levels of personal
skills concomitant with long experience in a post
and a high level of commitment, but a lack of tech-
nical skills reflecting a lack of basic education and
any training in health promotion. The ability to
provide a rationale for practice was also lacking and
the learners referred to common-sense in relation to
their activities.
Learner reaction
Many of the health promoters struggled academ-
ically, thinking analytically and synthesizing large
amounts of information proved very difficult for
individuals, most of whom had not read a book in
10 or 15 years. Nevertheless they valued the educa-
tion opportunity and the experience of attending a
university. All were able to identify knowledge and
practical skills gained as well as positive effects on
confidence and in the response of their clients. All
felt they had an improved understanding of health
promotion and its objectives with several employing
core concepts in the interview such as upstream and
downstream and client-centred approaches. Most
were delighted to have gained clarity on what their
job should entail as most were previously unsure of
their job description. Their enhanced ability to con-
ceptualise the health promotion role meant that
many felt their work was more important and valu-
able to the nation’s health and well-being. Most
hoped that this would also signal the beginning of
professionalization of their career coupled with
monetary and status rewards.
You know previously I had a big problem describ-
ing what health promotion is but now, I can really
see health promotion, where it fits in. It was diffi-
cult because people would think it was education
and now with the legislation of smoking policy and
all this stuff, domestic violence coming in I can tell
them my role and say no this is health promotion …
Acquisition of knowledge and skills
In relation to their health education role, several
health promoters felt that after attending the
modules, their talks were more structured and that
the topics and or content was not randomly selected
but rather more appropriate to the needs of the
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target community. Most cited the importance of
involving the audience by asking lots of questions to
assess their level of understanding and beliefs and to
draw on their experiences of the issue being dis-
cussed. Some even mentioned that the course had
changed communication at home and how they had
become less judgemental and more able to listen
to their children’s viewpoint. Many described
themselves as having a greater understanding of
communication, using a wider range of methods
and being more open to the range of issues that
individuals may wish to explore. While many
described their practice as empowering, this was
more akin to moving from being a prescriptive
advisor or information disseminator to facilitating
behaviour change:
I used to be giving advice where people were sup-
posed to take my advice then now with this train-
ing I realised you just have to give people
information then people will see which one or if
they will evaluate the information that they have
and them take a decision on it. You don’t have to
tell them what to do.
Impact on practice
While all the health promoters were convinced
that their practice had changed (with one exception)
they were less able to describe these changes. These
were described as better communication and facili-
tation skills as well as a greater understanding of the
social world and social determinants of health and
the importance of need-based approaches. Many
noted a benefit of being less judgemental and pre-
scriptive. Health promotion co-ordinators reported
being able to plan more systematically and provided
several examples of evidence being used to inform
the development of strategy.
The training has helped us upgrade and not give
old information or distorted messages.
Impact on the organization
Institutional constraints are serious and extend
across the whole group. Relationships with man-
agers and colleagues were frequently described as
difficult with widespread distrust and suspicion
of the training programme. Many of the health
 Original Article
promoters reported a conflict between their new
understanding and that of their managers who
expected health promoters to simply occupy patients
in clinic areas. Many health promoters reported that
their managers did not support them particularly in
their outreach activities.
Discussion
The evaluation of this training programme high-
lights many of the challenges facing the develop-
ment of a wider health promotion workforce. In
many countries there are large numbers of employed
(as distinct from lay) community health workers
and advocates who support a primary health care
system or community development projects. The
difficulties of describing their roles and assessing
their impact have been described by Lehmann and
Sanders (11). They are often not part of a profes-
sionalized workforce with little investment in their
training or career progression. Beaglehole (12), dis-
cussing the challenges of scaling up HIV/AIDS pro-
grammes, claims nearly 50% of health workers in
Chad have no formal skills training.
Is there a return on investment from training
health workers at this level? Most of the evidence
that we have reported here suggests that the pro-
gramme was successfully executed, and has pro-
duced early results that are consistent with its
objectives. A possible limitation of this study is that
it only reviewed the self-reported impact of the train-
ing on practice. Nevertheless the rich stories of the
informants report a radical shift in behaviour change
communication. Some of the longest-serving health
promoters had previously been employed in the pre-
democratic South Africa as family planning advisors
where a simple message had been promoted to the
African population to limit their family size. They
recounted now engaging with individuals and com-
munities with greater empathy and respect and
understanding of the complex nature of the behav-
iour change process in the context of everyday life.
In Gauteng the role of health promoter is offi-
cially recognised with a consistent title used, invest-
ment in training and a blue T-shirt is worn for ease
of identification. This is in contrast to the experi-
ence in many other provinces where numerous job
titles exist (6). Nevertheless many reported suspi-
cion, distrust and a lack of appreciation of the
health promotion role within the clinic setting
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33
leaving them demotivated and undermined in their
work. A hierarchical framework of a disease-ori-
ented health care system was described in which the
health promoters were seen as less important and as
mere assistants within health facilities, often com-
pletely misunderstanding their health promoting
and enabling role within communities. A similar
sense of superiority of health personnel has been
observed as a problem elsewhere (12). The role is
seen as less important and is confined to narrow
behaviour change approaches in part due to the
absence of occupational standards. Training had
however provided clarity about the health promo-
tion role and a confidence in being able to describe
and ‘own’ their practice.
Training for those with little academic standing
poses pedagogical and organizational challenges.
Early studies of the training of community health
workers queried its classroom-based and theoretical
nature (13). Rather than a traditional didactic
approach, this teaching programme was under-
pinned by a pedagogy in which students are
informed constructors of their learning: experiential
learning and reflections on practice act as the start-
ing point for the unpacking of theory and concepts
that students can then apply to identify new oppor-
tunities for health promotion. However the 25% of
health promoters without matriculation have not
yet taken this programme.
The benefits of a university leading a capacity
building initiative for health promotion can also be
debated. An academic environment proved daunt-
ing for these practitioners. In the absence of a com-
petency framework allowing for the assessment of
achieved skills, the course was bound by the regula-
tions governing academic levels. Yet, many students
did not have the basic skills required to read texts
and synthesize large quantities of information, and
were unable to write the assignments at a level that
is required for the certificate course as well as in
their work situation. The course now incorporates
skills development in literacy, study techniques and
has reduced the range of material giving more time
to explore concepts and develop competencies. On
the other hand, universities are expected to widen
participation and provide training opportunities,
and have the pedagogical experience to develop pro-
grammes underpinned by theory but sufficiently
applied to practice. Although it is too early in the
development of health promotion in South Africa
IUHPE – Global Health Promotion Vol.17, No. 3 2010
34 J. Wills and M. Rudolph
for a qualifying course to provide a step for career
progression, it did provide the participants with a
sense of self-worth.
Conclusions
Health promoters in South Africa have a wide
range of functions all of which demand effective
behaviour change communication and community
development skills. Although the cadre of health
providers are called health promoters, their role is
primarily one of health education addressing the
health literacy of the community. There is evidence
that community health workers, whose role is
similar to the health promoters in South Africa, can
show promising benefits in for example, promoting
immunization uptake and improving outcomes for
malaria (14). Lehmann and Sanders (11) conversely
claim they ‘do not consistently provide services likely
to have substantial health impact and the quality of
services they provide is sometimes poor’ (p. 26). This
evaluation indicates that training can enhance con-
tribution to health development by enabling health
promoters to provide client-centered information
and advice on key issues. It is also clear that training
alone is insufficient when the context for health pro-
motion in primary health care settings is unsupport-
ive. A focus on simply building skills among
individual practitioners alone will not lead to effec-
tive health promotion practice without strong
support from the organization within which they
work. Support from the provincial government and
a commitment of resources also will not change the
organizational culture and ways of working of local
health care facilities that can encourage and enable
or inhibit health promoters from using newly
learned competencies. As Waisbord (15) concludes
‘capacity building activities might then unintention-
ally contribute to promoting a sense of frustration
among participants who work in organizations that
provide little support to change job performance’
(p. 235). An organizational analysis of health promo-
tion for Gauteng Provincial Government (16) con-
cluded that while lack of support and clear channels
of communication in health care hindered health
promotion development, lack of transport was the
most significant obstacle. Capacity development for
health promotion in South Africa is clearly not syn-
onymous with the provision of training opportuni-
ties but the evaluation of this programme, the first
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post-school educational opportunity, indicates that
training can be a means for capacity-release.
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