Klaus B. von Pressentin

The roles and training of primary care doctors: China, India, Brazil and South Africa

China, India, Brazil and South Africa contain 40% of the global population and are key emerging economies. All these countries have a policy commitment to universal health coverage with an emphasis on primary health care. The primary care doctor is a key part of the health workforce, and this article, which is based on two workshops at the 2014 Towards Unity For Health Conference in Fortaleza, Brazil, compares and reflects on the roles and training of primary care doctors in these four countries.Key themes to emerge were the need for the primary care doctor to function in support of a primary care team that provides community-orientated and first-contact care. This necessitates task-shifting and an openness to adapt one’s role in line with the needs of the team and community. Beyond clinical competence, the primary care doctor may need to be a change agent, critical thinker, capability builder, collaborator and community advocate. Postgraduate training is important as well as up-skilling the existing workforce. There is a tension between training doctors to be community-orientated versus filling the procedural skills gaps at the facility level. In training, there is a need to plan postgraduate education at scale and reform the system to provide suitable incentives for doctors to choose this as a career path. Exposure should start at the undergraduate level. Learning outcomes should be socially accountable to the needs of the country and local communities, and graduates should be person-centred comprehensive generalists.

The perceived impact of family physicians on the district health system in South Africa : a cross-sectional survey

BackgroundEvidence from first world contexts support the notion that strong primary health care teams contain family physicians (FPs). African leaders are looking for evidence from their own context. The roles and scope of practice of FPs are also contextually defined. The South African family medicine discipline has agreed on six roles. These roles were incorporated into a family physician impact assessment tool, previously validated in the Western Cape Province.MethodsA cross-sectional study design was used to assess the perceived impact of family physicians across seven South African provinces. All FPs working in the district health system (DHS) of these seven provinces were invited to participate. Sixteen respondents (including the FP) per enrolled FP were asked to complete the validated 360-degree assessment tool.ResultsA total number of 52 FPs enrolled for the survey (a response rate of 56.5%) with a total number of 542 respondents. The mean number of respondents per FP was 10.4 (SD = 3.9). The perceived impact made by FPs was high for five of the six roles. Co-workers rated their FP’s impact across all six roles as higher, compared to the other doctors at the same facility. The perceived beneficial impact was experienced equally across the whole study setting, with no significant differences when comparing location (rural vs. metropolitan), facility type or training model (graduation before and ≥ 2011).ConclusionsThe findings support the need to increase the deployment of family physicians in the DHS and to increase the number being trained as per the national position paper.

Equipping family physician trainees as teachers: a qualitative evaluation of a twelve-week module on teaching and learning

BackgroundThere is a dire need to expand the capacity of institutions in Africa to educate health care professionals. Family physicians, as skilled all-rounders at district level, are potentially well placed to contribute to an extended training platform in this context. To play this role, they need to both have an understanding of their specialist role that incorporates teaching and be equipped for their role as trainers of current and future health workers and specialists. A teaching and learning capacity-building module was introduced into a new master’s programme in family medicine at Stellenbosch University, South Africa. We report on the influence of this module on graduates after the first six years.MethodsA qualitative study was undertaken, interviewing thirteen graduates of the programme. Thematic analysis of data was done by a team comprising tutors and graduates of the programme and an independent researcher. Ethical clearance was obtained.ResultsThe module influenced knowledge, skills and attitudes of respondents. Perceptions and evidence of changes in behaviour, changes in practice beyond the individual respondent and benefits to students and patients were apparent. Factors underlying these changes included the role of context and the role of personal factors. Contextual factors included clinical workload and opportunity pressure i.e., the pressure and responsibility to undertake teaching. Personal factors comprised self-confidence, modified attitudes and perceptions towards the roles of a family physician and towards learning and teaching, in addition to the acquisition of knowledge and skills in teaching and learning. The interaction between opportunity pressure and self-confidence influenced the application of what was learned about teaching.ConclusionsA module on teaching and learning influenced graduates’ perceptions of, and self-reported behaviour relating to, teaching as practicing family physicians. This has important implications for educating family physicians in and for Africa and indirectly on expanding capacity to educate health care professionals in Africa.

The Influence of Family Physicians Within the South African District Health System: A Cross-Sectional Study

PURPOSE Evidence of the influence of family physicians on health care is required to assist managers and policy makers with human resource planning in Africa. The international argument for family physicians derives mainly from research in high-income countries, so this study aimed to evaluate the influence of family physicians on the South African district health system. METHODS We conducted a cross-sectional observational study in 7 South African provinces, comparing 15 district hospitals and 15 community health centers (primary care facilities) with family physicians and the same numbers without family physicians. Facilities with and without family physicians were matched on factors such as province, setting, and size. RESULTS Among district hospitals, those with family physicians generally scored better on indicators of health system performance and clinical processes, and they had significantly fewer modifiable factors associated with pediatric mortality (mean, 2.2 vs 4.7, P =.049). In contrast, among community health centers, those with family physicians generally scored more poorly on indicators of health system performance and clinical processes, with significantly poorer mean scores for continuity of care (2.79 vs 3.03; P =.03) and coordination of care (3.05 vs 3.51; P =.02). CONCLUSIONS In this study, having family physicians on staff was associated with better indicators of performance and processes in district hospitals but not in community health centers. The latter was surprising and is inconsistent with the global literature, suggesting that further research is needed on the influence of family physicians at the primary care level.

Examining the influence of family physician supply on district health system performance in South Africa: An ecological analysis of key health indicators

Background The supply of appropriate health workers is a key building block in the World Health Organization’s model of effective health systems. Primary care teams are stronger if they contain doctors with postgraduate training in family medicine. The contribution of such family physicians to the performance of primary care systems has not been evaluated in the African context. Family physicians with postgraduate training entered the South African district health system (DHS) from 2011. Aim This study aimed to evaluate the impact of family physicians within the DHS of South Africa. The objectives were to evaluate the impact of an increase in family physician supply in each district (number per 10 000 population) on key health indicators. Setting All 52 South African health districts were included as units of analysis. Methods An ecological study evaluated the correlations between the supply of family physicians and routinely collected data on district performance for two time periods: 2010/2011 and 2014/2015. Results Five years after the introduction of the new generation of family physicians, this study showed no demonstrable correlation between family physician supply and improved health indicators from the macro-perspective of the district. Conclusion The lack of a measurable impact at the level of the district is most likely because of the very low supply of family physicians in the public sector. Studies which evaluate impact closer to the family physician’s circle of control may be better positioned to demonstrate a measurable impact in the short term.

African primary care research : current situation, priorities and capacity building

CITATION: Mash, R., et al. 2014. African primary care research: Current situation, priorities and capacity building. African Journal of Primary Health Care & Family Medicine, 6(1): 1-6, doi: 10.4102/phcfm.v6i1.75.

The impact of family physician supply on district health system performance, clinical processes and clinical outcomes in the Western Cape Province, South Africa (2011–2014)

Background A revised family physician (FP) training programme was introduced in South Africa in 2007. A baseline assessment (2011) of the impact of FP supply on district health system performance was performed within the Western Cape Province, South Africa. The impact of an increased FP supply within this province required re-evaluation. Aim To assess the impact of FP supply on indicators of district health system performance, clinical processes and clinical outcomes in the Western Cape Province. The objectives were to determine the impact of FPs, nurses, medical officers (MOs) and other specialists. Setting The study sample included all five rural districts and eight urban subdistricts of the Western Cape Province. Methods A secondary analysis was performed on routinely collected data from the Western Cape Department of Health from 01 March 2011 until 30 April 2014. Results The FP supply did not significantly impact the indicators analysed. The supply of nurses and MOs had an impact on some of the indicators analysed. Conclusion This study did not replicate the positive associations between an increase in FP supply and improved health indicators, as described previously for high-income country settings. The impact of FP supply on clinical processes, health system performance and outcome indicators in the Western Cape Province was not statistically significant. Future re-evaluation is recommended to allow for more time and an increase in FP supply.

Corticosteroids in sports-related injuries: Friend or Foe

The international #1WordforFamilyMedicine initiative serves to explore the identity of family physicians and allows the international Family Medicine community to collaborate on advocating the discipline. South African family physicians provided 42 responses via a social media and online survey. Two “word cloud” images were created based on two icons recognised as being truly South African around the world – that of the national flag and former president Nelson Mandela. The #1WorldforFamilyMedicine initiative was promoted by the World Organization of Family Doctors across the globe to help celebrate World Family Doctor Day on 19 May 2015. To date, over 70 images have been created in 50 different countries on six continents. The images represent family physicians’ love for their profession and the community they serve. It is hoped that this initiative will help to inspire current and future Family Medicine and primary care providers.