The changing fortunes of the District Health System in SA (1994 - 2020): A retrospective review

The District Health System (DHS) forms the foundation of South Africa (SA)'s public health system. Following years of fragmentation and inequity during the apartheid era, building the DHS was seen as a vital element of the strategy to reform the health system in line with the principles of primary healthcare (PHC). SA has made great strides in establishing and strengthening the DHS, and to date there are 52 districts and 240 subdistricts. This process unfolded in a complex, and often challenging, social and political context.

To present an historical account of the DHS as a focus of national-level policy and strategy from 1994 to present. In doing so, we aim to illuminate the factors influencing DHS development over time, and contribute to an historically aware understanding of SA's DHS and its contemporary challenges.

We conducted a retrospective scoping review of literature on the DHS in SA from 1994 to 2020. We used database searches to identify primary and secondary documentary evidence, supplemented by purposive searches of databases and institutional repositories, and published and unpublished documentary evidence from the personal archives of key stakeholders. We extracted data on the timing of policy developments and contextual factors influencing DHS prioritisation and strategy using a structured data extraction sheet. Once extracted, this information was organised into a timeline.

After full-text review, 134 items were included for analysis. Based on the data analysis, we divided the events of the policy timeline into three periods: 1994 - 2000 (developing the legislative framework for the DHS, establishing local government boundaries and building district-level capacity), 2001 - 2009 (finalisation of the National Health Act, and the effects of the HIV epidemic and vertical health programmes on the DHS), and 2010 - 2020 (development of National Health Insurance legislation and associated efforts to strengthen PHC). This periodisation reflects differences in the pace of policy change, the extent of political prioritisation of the DHS and contextual factors influencing its development.

Sustained political commitment to DHS development in SA is evident. However, the development and implementation of the DHS have been both enabled and constrained by various contextual realities, and is best understood in relation to wider health system and sociopolitical dynamics. Further in-depth analyses of the nature, focus and limits of DHS strengthening efforts are warranted. In particular, history-sensitive analyses of the sociopolitical factors that shaped the development of the DHS will inform strengthening efforts going forward.