In developing countries – and particularly in sub-Saharan Africa – most primary care services are offered by nurses, not doctors as is the case in developed countries. In addition most of the doctors have no specific training in family medicine or primary care.
South Africa is no exception. But the country has been experimenting with a different approach. Over the past few decades family physicians, specialists in family medicine, have been sent to work in the district health system. The result is that many community health centres and district hospitals now have family physicians. The numbers are still small with on average two family physicians per health district. The country has 52 health districts.
We set out to evaluate how family physicians are contributing to South Africa’s district health system. As part of our study, we looked at the impact of family physicians in district hospitals and community health centres across seven provinces.
While South Africa has better human resources for health than most other African countries, it is still less than comparable middle income countries such as Brazil. South Africa has about 77 doctors for 100,000 people compared to 206 for every 100,000 people in Brazil. And of the available doctors, only about 41% work in the public sector that looks after 80% of the population. Doctors are concentrated in urban areas and coverage varies between provinces. Currently there is about one family physician for every 100,000 people in the country. In the public sector this translates into 0.3 for every 100,000 people. By comparison Brazil has twice as many family physicians.
South Africa’s health needs are considerable because it faces a quadruple burden of disease in the form of HIV/AIDS, tuberculosis; maternal and child health problems; non-communicable diseases as well as trauma and violence-related injuries.
We found that South Africa’s family physicians are making a significant contribution to health care. They are improving access to quality care and reduce the need to refer patients elsewhere. This is because they are bringing a more comprehensive set of clinical competencies closer to the community and strengthening the whole health care team.
They also improve the organisation of care for patients and the quality of care for conditions such as HIV, TB, mental health, non-communicable diseases, maternal, child and emergency care. As a result the health and well-being of millions of people who can’t afford medical insurance are being improved. This was confirmed by district hospital managers as well as their co-workers.
And in the context of improving health care in South Africa, our study has underpinned the need for more family physicians to be employed in the public health systems, particularly in isolated areas.
What are family physicians?
Most regions of the world, apart from Africa, have well established postgraduate training programmes in family medicine for their doctors. In some countries, such as the UK, it is now compulsory for general practitioners to have such training. These countries recognise the complexity of assessing and managing undifferentiated health problems in primary care.
In the African context additional competencies are required to work in district hospitals. Unlike general practitioners and medical officers, family physicians complete four years of additional training after their basic degree.
In South Africa, family physicians are a relatively new innovation in the health system. They were only formally recognised in 2007 as specialists in family medicine.
A two-year diploma in family medicine has also recently been created to meet the learning needs of doctors working in the district health system that do not want to specialise.
The additional training makes family physicians expert medical generalists who are not only competent clinicians, but also consultants, capacity builders, leaders of quality improvement and champions of community-oriented primary care.
In the public sector family physicians are employed in district hospitals, often in rural areas where there are no other specialists and significant skills gaps in current service provision. They are also trained to work in primary health care. There they support the multidisciplinary team of medical officers, nurses, community health workers and other allied health workers.
For family physicians to really make a difference in the public sector, there should be at least one placed at every district hospital and community health centre in the country. This means that there should initially be 700 family physicians employed in the public sector. Currently there are just over 1,000 family physicians registered in South Africa – but less than a third work in the public sector.
The placement of family physicians in the public sector isn’t always ideal. This is because there’s still confusion in national policy and different interpretations on how best to employ family physicians. Provinces are employing them in different ways – sometimes using them as members of district clinical specialist teams or to fill gaps in the system when they lack clinical managers or other specialists.
But South Africa can’t afford to duck the problem. One of its commitments in the UN’s sustainable development goals is to improve universal health coverage in the country. If this is to become a reality, employing more well-trained family physicians in the country’s district health system is an important step.