Shabir Moosa

Exploring the Key Principles of Family Medicine in Sub-Saharan Africa: International Delphi Consensus Process

Abstract Background: The purpose of this study was to establish consensus on the key principles of Family Medicine for Sub-Saharan Africa. Methods: A three-stage Delphi technique process involving nine countries in sub-Saharan Africa and individuals from two stakeholder groups (teachers or students/graduates of family medicine programmes). Consensus in rounds one and two was defined as at least 70% agreement. Ranking in round three depended on individuals selecting and ranking the top 20 principles; following this, aggregate scores were calculated. Results: Of the participants, 40 gave consent and 28 participated in the first round (23 teachers and 17 students/graduates); 27/40 (67.5%) participated in the second round; 22/40 (60%) in the third round. The 50 principles seen as relevant were ranked in order of importance. Core values and characteristics such as holistic, longitudinal, comprehensive and family-orientated care and community orientation were recognised as relevant, with differences from more developed settings in terms of emphasis. Several key organisational principles, such as home visiting and definition of the practice population, were seen differently. Principles relating to the scope of practice showed the greatest difference, with the need for family physicians to perform major surgery in the district hospital, to act as consultant and teacher to the first-contact primary care team and to include clinical nurse practitioners in the definition of family medicine being raised. Conclusion: The study contributes towards a clearer definition of Family Medicine in the region, which would enable comparison between regions, influence local curriculum content and outcomes, as well as inform the policy makers and managers of the health system.

Primary health care in a changing world

This article considers the changing nature of primary health care in a changing international context. Four family physicians from four continents and all involved in the change process, reflect on the developments in primary health care as they perceive them. Jan De Maeseneer was involved in the incremental strengthening of primary health care in Belgium and has an international perspective as Chairman of the European Forum for Primary Care. Shabir Moosa is the acting chief specialist of District Health Services in Gauteng (South Africa) and coordinates a project on strengthening family medicine training in Africa. Yongyuth Pongsupap is the primary care component manager of Health Care Reform Project and expert in health policy at the National Health Security Office in Nonthaburi (Thailand). He has been working as a GP in a new established health centre since he was assigned as a pilot family doctor in 1991. Arthur Kaufman is involved in programmes for better access to health care for vulnerable groups and in primary care innovations in the state of New Mexico (US). Today, we face unprecedented demographic and epidemiologic transitions. The world population is aging rapidly. In 2005, 19% of all deaths were among children and 53% were among people aged 60 years and older. By 2030 the respective proportions will have changed to 9% and 62%.1 Non-communicable disease mortality will increase from 61% to 68% worldwide, and a similar trend will occur in Africa despite the HIV/AIDS pandemic and poor socioeconomic circumstances. As the population ages, the number of people with multimorbidity (two or more chronic conditions) will increase.2 There are wide differences in healthy life expectancy across the world: for Africa, healthy life expectancy is 40 years for males and 42 years for females, for Europe it is 62 and 68 years respectively.3 Encouragingly, …

Why sub-Saharan African health workers migrate to european countries that do not actively recruit: A qualitative study post-migration

Background Many studies have investigated the migration intentions of sub-Saharan African medical students and health professionals within the context of a legacy of active international recruitment by receiving countries. However, many health workers migrate outside of this recruitment paradigm. This paper aims to explore the reasons for migration of health workers from sub-Saharan Africa to Belgium and Austria; European countries without a history of active recruitment in sub-Saharan Africa. Methods Data were collected using semistructured interviews. Twenty-seven health workers were interviewed about their migration experiences. Included participants were born in sub-Saharan Africa, had trained as health workers in sub-Saharan Africa, and were currently living in Belgium or Austria, though not necessarily currently working as a health professional. Results Both Austria and Belgium were shown not to be target countries for the health workers, who instead moved there by circumstance, rather than choice. Three principal reasons for migration were reported: 1) educational purposes; 2) political instability or insecurity in their country of origin; and 3) family reunification. In addition, two respondents mentioned medical reasons and, although less explicit, economic factors were also involved in several of the respondents’ decision to migrate. Conclusion These results highlight the importance of the broader economic, social, and political context within which migration decisions are made. Training opportunities proved to be an important factor for migration. A further development and upgrade of primary care might help to counter the common desire to specialize and improve domestic training opportunities.

Why there is an inverse primary-care law in Africa

www.thelancet.com/lancetgh Vol 1 December 2013 e332 universal health coverage—a goodquality clinical workforce is needed that has access to diagnostic and treatment facilities, and is incentivised to work where it is most needed. In low-income and middle-income countries, this need is invariably greatest in primary care and fi rst-contact care, both because of the nature of the health services that most need to be delivered, and the importance of primary care for health-system cost-eff ectiveness. The inescapable and unrecognised implication of what our respondents said is that, in most of sub-Saharan Africa, effective primary care is not going to happen. Clinicians will not work in the conditions they experience in primary care, and these conditions are getting progressively worse as the need for effective primary care increases—thus the situation could be called the inverse primary care law. The policy discourse on universal health care in Africa now needs to focus on how to provide the necessary human resources to staff and deliver primary care eff ectively. Demand-led payment systems, such as payment by results, cannot drive up care quality unless there is a supply of well trained and well supported clinical staff to meet the demand. Innovative supply-side solutions could address poor working environments and career paths in primary care. Until these solutions are prioritised and implemented, the global poor are condemned to receive poor care or no care at all.

The inverse primary care law in sub-Saharan Africa: a qualitative study of the views of migrant health workers

BACKGROUND Many low-income and middle-income countries globally are now pursuing ambitious plans for universal primary care, but are failing to deliver adequate care quality because of intractable human resource problems. AIM To understand why migrant nurses and doctors from sub-Saharan Africa did not wish to take up available posts in primary and first-contact care in their home countries. DESIGN AND SETTING Qualitative study of migrant health workers to Europe (UK, Belgium, and Austria) or southern Africa (Botswana and South Africa) from sub-Saharan Africa. METHOD Semi-structured interviews with 66 health workers (24 nurses and 42 doctors) from 18 countries between July 2011 and April 2012. Transcripts were analysed thematically using a framework approach. RESULTS The reasons given for choosing not to work in primary care were grouped into three main analytic streams: poor working environment, difficult living experiences, and poor career path. Responders described a lack of basic medicines and equipment, an unmanageable workload, and lack of professional support. Many had concerns about personal security, living conditions (such as education for children), and poor income. Primary care was seen as lower status than hospital medicine, with lack of specialist training opportunities and more exposure to corruption. CONCLUSIONS Clinicians are reluctant to work in the conditions they currently experience in primary care in sub-Saharan Africa and these conditions tend to get worse as poverty and need for primary care increases. This inverse primary care law undermines achievement of universal health coverage. Policy experience from countries outside Africa shows that it is not immutable.

Human resources for primary health care in sub-Saharan Africa: progress or stagnation?

BackgroundThe World Health Organization defines a “critical shortage” of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years.MethodsThis study is a review of published and unpublished “grey” literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa.ResultsHealth worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers.ConclusionThere is an “inverse primary health care law” in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.

Security and skills: the two key issues in health worker migration

Background Migration of health workers from Africa continues to undermine the universal provision of quality health care. South Africa is an epicentre for migration – it exports more health workers to high-income countries than any other African country and imports health workers from its lower-income neighbours to fill the gap. Although an inter-governmental agreement in 2003 reduced the very high numbers migrating from South Africa to the United Kingdom, migration continues to other high-income English-speaking countries and few workers seem to return although the financial incentive to work abroad has lessened. A deeper understanding of reasons for migration from South Africa and post-migration experiences is therefore needed to underpin policy which is developed in order to improve retention within source countries and encourage return. Methods Semi-structured interviews were conducted with 16 South African doctors and nurses who had migrated to the United Kingdom. Interviews explored factors influencing the decision to migrate and post-migration experiences. Results Salary, career progression, and poor working conditions were not major push factors for migration. Many health workers reported that they had previously overcome these issues within the South African healthcare system by migrating to the private sector. Overwhelmingly, the major push factors were insecurity, high levels of crime, and racial tension. Although the wish to work and train in what was perceived to be a first-class care system was a pull factor to migrate to the United Kingdom, many were disappointed by the experience. Instead of obtaining new skills, many (particularly nurses) felt they had become ‘de-skilled’. Many also felt that working conditions and opportunities for them in the UK National Health Service (NHS) compared unfavourably with the private sector in South Africa. Conclusions Migration from South Africa seems unlikely to diminish until the major concerns over security, crime, and racial tensions are resolved. However, good working conditions in the private sector in South Africa provide an occupational incentive to return if security did improve. Potential migrants should be made more aware of the risks of losing skills while working abroad that might prejudice return. In addition, re-skilling initiatives should be encouraged.

African leaders’ views on critical human resource issues for the implementation of family medicine in Africa

BackgroundThe World Health Organisation has advocated for comprehensive primary care teams, which include family physicians. However, despite (or because of) severe doctor shortages in Africa, there is insufficient clarity on the role of the family physician in the primary health care team. Instead there is a trend towards task shifting without thought for teamwork, which runs the risk of dangerous oversimplification. It is not clear how African leaders understand the challenges of implementing family medicine, especially in human resource terms. This study, therefore, sought to explore the views of academic and government leaders on critical human resource issues for implementation of family medicine in Africa.MethodIn this qualitative study, key academic and government leaders were purposively selected from sixteen African countries. In-depth interviews were conducted using an interview guide. All interviews were audio-recorded, transcribed and thematically analysed.ResultsThere were 27 interviews conducted with 16 government and 11 academic leaders in nine Sub-Saharan African countries: Botswana, Democratic Republic of Congo, Ghana, Kenya, Malawi, Nigeria, Rwanda, South Africa and Uganda. Respondents spoke about: educating doctors in family medicine suited to Africa, including procedural skills and holistic care, to address the difficulty of recruiting and retaining doctors in rural and underserved areas; planning for primary health care teams, including family physicians; new supervisory models in primary health care; and general human resource management issues.ConclusionsImportant milestones in African health care fail to specifically address the human resource issues of integrated primary health care teamwork that includes family physicians. Leaders interviewed in this study, however, proposed organising the district health system with a strong embrace of family medicine in Africa, especially with regard to providing clinical leadership in team-based primary health care. Whilst these leaders focussed positively on entry and workforce issues, in terms of the 2006 World Health Report on human resources for health, they did not substantially address retention of family physicians. Family physicians need to respond to the challenge by respondents to articulate human resource policies appropriate to Africa, including the organisational development of the primary health care team with more sophisticated skills and teamwork.

The views of key leaders in South Africa on implementation of family medicine: critical role in the district health system

BackgroundIntegrated team-based primary care is an international imperative. This is required more so in Africa, where fragmented verticalised care dominates. South Africa is trying to address this with health reforms, including Primary Health Care Re-engineering. Family physicians are already contributing to primary care despite family medicine being only fully registered as a full specialty in South Africa in 2008. However the views of leaders on family medicine and the role of family physicians is not clear, especially with recent health reforms. The aim of this study was to understand the views of key government and academic leaders in South Africa on family medicine, roles of family physicians and human resource issues.MethodsThis was a qualitative study with academic and government leaders across South Africa. In-depth interviews were conducted with sixteen purposively selected leaders using an interview guide. Thematic content analysis was based on the framework method.ResultsWhilst family physicians were seen as critical to the district health system there was ambivalence on their leadership role and ‘specialist’ status. National health reforms were creating both threats and opportunities for family medicine. Three key roles for family physicians emerged: supporting referrals; clinical governance/quality improvement; and providing support to community-oriented care. Respondents’ urged family physicians to consolidate the development and training of family physicians, and shape human resource policy to include family physicians.ConclusionsFamily physicians were seen as critical to the district health system in South Africa despite difficulties around their precise role. Whilst their role was dominated by filling gaps at district hospitals to reduce referrals it extended to clinical governance and developing community-oriented primary care - a tall order, requiring strong teamwork. Innovative team-based service delivery is possible despite human resource challenges, but requires family physicians to proactively develop team-based models of care, reform education and advocate for clearer policy, based on the views of these respondents.

Perspectives on key principles of generalist medical practice in public service in sub-Saharan Africa: a qualitative study.

BackgroundThe principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context.MethodsA descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed.ResultsThe respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patients perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being life-long learners themselves. However, their role in the community, was found to be more aspirational than real.ConclusionsThe study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.