Repositioning Community Health Workers as Boundary Spanners: A Realist-Informed Theory of Change for Integrated People-Centred Care in South Africa

Background Community Health Workers (CHWs) are central to South Africa’s primary health care (PHC) reforms yet remain under-recognised as actors who can coordinate care across sectors. This paper reconceptualises CHWs as boundary spanners and presents a realist-informed Theory of Change (RiToC) to support this shift. Methods We conducted a qualitative realist-informed conceptual synthesis, drawing on four interlinked data sources: a realist synthesis of CHW studies from sub-Saharan Africa, a realist evaluation of CHW-household interactions, a realist evaluation of a collaborative governance platform, and a systems-level reframing of the WHO Integrated People-Centred Health Services (IPCHS) framework. Insights were synthesised into a RiToC to guide how CHWs can be supported to perform integrative functions across health, social, and governance systems. Findings: CHWs already perform relational and coordinative functions that connect communities with clinics, social services, and local governance structures, though these roles are often informal and under-recognised. We identify seven strategic levers to strengthen CHWs’ capacity as boundary spanners: layered accountability, shared ownership, equitable resourcing, multisectoral training, professional recognition, adaptive models, and multisectoral integrated tools. The RiToC provides a roadmap for embedding CHWs into PHC reform and multisectoral governance by clarifying enabling conditions and mechanisms that support them as boundary spanners who can deliver IPCHS. Conclusion CHWs are already de facto boundary spanners. Unlocking their potential requires redesigning systems and policies to support their roles across sectors. Methodologically, this study advances RiToC as an innovation that combines explanatory depth with practical design, offering a transferable approach for strengthening community health systems in complex settings.