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# Background Primary health care (PHC) in most African countries is nurse led. In South Africa, PHC has a unique history where efforts to provide holistic health care to rural communities began in the early 1940s. There are initiatives to ensure that doctors including General Practitioners (GPs) get to public clinics in South Africa-great initiatives but bearing in mind the current doctor patient ratios and the difficulties to get doctors into rural areas, until we get there, nurses will be and are providing most of PHC services. # Methods We tracked policy implementation aimed at achieving Universal Health Coverage in one pilot district in South Africa from 2011-2015. Qualitative data was collected during three phases 2011-2012 (Contextual mapping), 2013-2014 (Phase 1) and 2015 (Phase 2). A theory of change approach was employed. Semi-structured in-depth interviews were held with participants using a standard interview guide. Participants ranged from provincial, district, sub-district and facility actors involved in policy implementation. # Results Many health systems strengthening activities are being carried out namely; PHC re-engineering package made up of district clinical specialists, school health and ward based teams, referral systems strengthening, management strengthening, and general practitioner (GP) contracting. # Conclusions We found no targeted health systems strengthening initiatives to counteract the challenges faced by PHC nurses which are well documented in literature. What we see currently missing are initiatives directed at the work done by nurses in a PHC setting, to assist them resolve the so well documented challenges they are faced with in their daily work. If PHC is nurse led, we advocate going step by step with the aid of the nursing process and assess what could be done to streamline, strengthen, innovate and support the work a PHC nurse does, guided by systems thinking, hence we propose a Framework for Health Systems Strengthening in a nurse led PHC setting, that takes into account the challenges and the roles of a PHC nurse Figure 1.