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Introduction South Africa is experiencing a significant shift in its disease burden from high HIV and tuberculosis (TB) mortality to increased burden of non-communicable diseases (NCDs). Despite this, screening, treatment and control for NCDs remain limited. Community health fairs are often used to identify and refer individuals with chronic diseases in underserved areas, but their impact on morbidity and mortality is unclear.Methods From 2018 to 2020, individuals aged 15+ in the Africa Health Research Institute’s demographic surveillance area in rural KwaZulu-Natal were invited to Vukuzazi, a community health fair programme offering screening and referrals for HIV, TB, hypertension and diabetes. All residents were followed through regular household surveillance to identify deaths. We used inverse probability of treatment weighting survival analysis to estimate the effect of attendance on all-cause mortality and logistic regression to assess whether any difference in mortality may be explained by increased access to care.Results Of those eligible, 18 041 (50.0%) participated in Vukuzazi. Individuals were observed after the health fairs for a median of 4.0 years (IQR 3.7–4.2 years) comprising a total of 127 625 person years. Vukuzazi health fair attendance was associated with a 25% relative reduction in the hazard of all-cause mortality (HR=0.75, 95% CI 0.67 to 0.84), corresponding to a 1.5% absolute reduction in mortality over 5 years. In the 3 months post health fair, attenders had 13% increased odds of clinic attendance (OR=1.13, 95% CI 1.10 to 1.17), but no change in clinic attendance among non-attenders (OR=1.02, 95% CI 0.98 to 1.06).Conclusion Participation in a community-based health fair was associated with a reduction in 5-year all-cause mortality in rural South Africa. The reduced mortality in those attending corresponded to an increase in primary healthcare engagement following the health fairs. The integration of health fairs with a paired referral system may be an effective strategy to improve health outcomes in the region.