They may be few in number, but South Africa’s family physicians make a significant contribution to health care in South Africa. They help to strengthen the country’s district health system and improve the health and well-being of millions of people who can’t afford medical insurance.
This is one of the key findings of a new study at Stellenbosch University (SU).
“Family physicians help to alleviate the quadruple burden of HIV/AIDS and tuberculosis; maternal and child health problems; non-communicable diseases as well as trauma and violence-related injuries among many South Africans,” says Dr Klaus von Pressentin, a family physician from Mossel Bay.
Von Pressentin recently obtained his doctorate in Family Medicine at SU under the supervision of Prof Bob Mash from the Division of Family Medicine and Primary Care in SU’s Faculty of Medicine and Health Sciences. The study aimed to evaluate the contribution of family physicians to South Africa’s district health system.
Family physicians are expert generalists who have successfully completed postgraduate training in Family Medicine. An expert generalist is someone who has knowledge of different fields and apply this knowledge to his/her core speciality. There are currently 950 family physicians registered with the Health Professions Council of South Africa but not all are working in the (district health system) public sector. At the beginning of 2015, there were 209 family physicians working within the district health system.
As part of the study, Von Pressentin looked at the impact of 52 family physicians within 52 health districts across seven provinces (Western Cape, Northern Cape, Gauteng, North West, Free State, KwaZulu-Natal and Mpumalanga) and how they help to strengthen the district health system. To determine this, he used a 360-degree survey to gather information from 542 co-workers of these physicians across the seven provinces.
In addition, 21 district managers from these seven provinces were interviewed regarding the impact of all the family physicians in their districts. Von Pressentin compared 30 district health facilities that had family physicians to 30 without family physicians and also evaluated the correlations between the supply of family physicians in each district and key health system performance indicators, key clinical processes and key health outcomes.
According to Von Pressentin, family physicians help strengthen the district health system by performing six important roles that complement each other during their day-to-day activities (i.e. interacting with patients, colleagues, managers and students).
“They provide care to patients; support other health practitioners; mentor and train less qualified clinicians; offer clinical training to medical students, clinical associate trainees, interns or registrars; improve the quality of clinical services within their sub-district and facility; and champion community-orientated primary health care.”
“Co-workers of family physicians rated their impact across these six roles as higher compared to the other doctors at the same facility.”
“District managers confirmed the importance of all six roles of the family physician and expressed both direct and indirect ways in which family physicians contribute to strengthening health systems’ performance and clinical outcomes. Family physicians were seen as important clinical leaders within the district healthcare team.”
“The feedback of district managers also highlighted that family physicians’ ability to act as leaders and influence their colleagues is a key factor in determining their impact on the health outcomes of the community they serve.”
Von Pressentin adds that district hospitals with family physicians on staff had better outcomes in terms of health system performance and clinical processes. He points out, however, that this was not the case in community health centres.
“The latter was surprising and is inconsistent with the global literature that reports the family physician as being ideally placed to improve primary health care generally and to enhance continuity and coordination of care specifically.”
Von Pressentin says it could be because family physicians were deployed where the need was greatest and that their training prepared them better for district hospitals as opposed to community health centres. Chances are their influence was greater within the management structure at district hospitals than in primary health care, he adds.
Not enough family physicians
Given South Africa’s health challenges, Von Pressentin says the study highlights the need for more family physicians in addition to those who are already helping to improve health care.
“We must continue to employ more well-trained family physicians within the country’s district health system as the current supply is too low and yet key findings support the early beneficial influence of family physicians on the system.”
“It is important to create more posts for family physicians in both metropolitan and rural districts, and in both district hospitals and community health centres.”
Von Pressentin says creating more family physicians posts will help to support the implementation of family medicine within the district health system, especially in areas with no or isolated family physicians.
“International research has shown that health systems are stronger if they adopt the primary health care approach and include family physicians in their primary care teams.”
He also emphasises the importance of role clarification and support that family physicians need to fulfil these roles.
“District managers agreed that family physicians, their team members (including senior colleagues, other specialists, local and district managers), as well as the academic training coordinators should engage in ongoing conversations around role-clarification, mentoring support (senior family physicians) and role maturation (from clinician/consultant to clinical governance leader and trainer) as it applies to each local context.”
Von Pressentin points out that there is still uncertainty around policy and different interpretations on how best to employ family physicians.
With family medicine being a relatively young discipline, he says more research is required to help convince the leadership of the Department of Health, higher education institutions, as well as the national health professions licensing body to buy into the investment in family physicians.
Von Pressentin says he hopes this research may function as a catalyst for future studies, strengthen research collaborations and help develop family medicine in South Africa.