subscribe Support our award-winning journalism. The Premium package (digital only) is R30 for the first month and thereafter you pay R129 p/m now ad-free for all subscribers.
Subscribe now
Family physicians undergo an extra four years of training, with an emphasis on clinical governance and knowledge of social factors influencing people’s health. Picture: Hush Naidoo/Unsplash
Family physicians undergo an extra four years of training, with an emphasis on clinical governance and knowledge of social factors influencing people’s health. Picture: Hush Naidoo/Unsplash

The national department of health has signalled that it wants to see more family physicians appointed as clinical managers tasked with leading multidisciplinary district hospital teams. This follows years of lobbying by the South African Academy of Family Physicians (SAAFP) advocating for the greater utilisation of family physicians in the country’s public health-care system. 

The SAAFP has long argued the cost and clinical effectiveness of these “super generalists”, who undergo an extra four years of training, with an emphasis on clinical governance and knowledge of social factors influencing people’s health. And it seems their patience has been rewarded with a five-year district health blueprint from the government. 

This was confirmed to Spotlight by Luvuyo Bayeni, chief director of human resources for health at the national health department. 

Advocates for the specialty argue that family physicians have been neglected, with posts thin on the ground and their potential contribution underestimated. The discipline was registered with the Health Professions Council of South Africa in 2007. 

Bob Mash, distinguished professor at Stellenbosch University, where he heads the division of family medicine and primary care, describes the specialty as “one of the most underutilised solutions to many of the problems facing district health service delivery”. Mash is the immediate past president of the SAAFP. 

Bayeni, a former clinician/administrator in the Eastern Cape, was appointed to lead the health department’s human resource operations in July last year. Since then, he attended the last two annual SAAFP conferences and has been meeting regularly with the academy’s leadership. 

With austerity measures being the catch-all rebuttal by provincial heads of department whenever the wisdom of freezing posts is questioned, Bayeni is trying to persuade his provincial counterparts to adopt a policy of appointing family physicians to clinical manager posts as a highly cost-efficient move, citing successes in the Western Cape. The idea is that family physicians are able to quickly diagnose and treat patients while mentoring junior colleagues. They also help design or tweak hospital and referral clinic systems for efficiency and identify preventative health interventions at community level. 

Blueprint approved 

Bayeni tells Spotlight his family medicine-oriented blueprint has been approved by the presidency’s department of planning, monitoring & evaluation for inclusion in all future health indicators. His plan is to initially get family physicians as clinical managers into all medium to large district hospitals (150 beds and above), before ensuring they are placed in every health district, including at lower-level hospitals and community health centres, at all times leading a multidisciplinary team. 

“Instead of waiting for HR plans and organograms, this is going into the midterm framework for monitoring. It’s a strategic opportunity, where we ask ourselves: ‘How do we define a multidisciplinary team for a district hospital?’ and then work through and with them. We’ll define and map where our priority district hospitals are, starting with the medium to large district hospitals.”

Bayeni says he met with his provincial counterparts and military health service chiefs last week, where he says he was going to “make sure they all know about this. Organograms are all fine and well and necessary, but I want this top of mind when they consider them.” 

He adds: “Personally, by April next year [the new financial year], I want to see more family physicians being appointed, either in the district or in the position of clinical managers wherever there are vacancies. I’ll ask the provinces to help me with monitoring and evaluation.” 

His ambition is to change the mindset of provincial health-care leaders “wherever necessary” about family physicians being regarded as “just another specialty” when creating and enumerating posts. 

They join the dots rather than work in silos like other specialties who tend to guard their turf jealously
Steve Reid

Positive responses 

Several top family medicine academics and clinicians around the country who have been at the forefront of providing data and lobbying for a more pragmatic health-care delivery approach have welcomed the renewed focus on family physicians. 

Prof Steve Reid, a veteran rural family physician and head of primary health care at the University of Cape Town (UCT), tells Spotlight the main problem is what he calls a framing issue. 

“The way we think about medicine is to just go to the doctor and get it sorted, rather than how a huge number of diseases can be managed and prevented early on — it’s been a major shift over the past 50 years. I mean, we now have studies that link prenatal health to later chronic diseases. The whole idea of social medicine went out of vogue, and the idea that health has far more to do with the social determinants of health than it has to do with the health system had too little purchase,” he says. 

Reid observes that no family physician can work in isolation — they make the most difference when they have a multidisciplinary team around them. 

Labelling family physicians “boundary-spanners par excellence”, he says “they join the dots rather than work in silos like other specialties who tend to guard their turf jealously”. 

He adds: “Brazil is a middle-income country just like South Africa and their simple model of one doctor, a nurse and four to six community health workers per 4,000 population has got 80% of their population covered, including vast urban areas like São Paulo and Rio de Janeiro.” In South Africa’s case, having a family physician as the leader will further enhance this model. 

‘About 400 needed’ 

Mash says South Africa’s previous health policies saw family physicians as a subspecialty of internal medicine or as specialists who should work at tertiary hospitals and within primary care teams. Currently, chiefly due to the lack of posts, only a third of family medicine graduates are retained in the public sector, with 10% emigrating and 11% giving up medicine altogether. Most are employed in the Western Cape, where the health system had committed to appointing family medicine practitioners at district hospitals and primary care facilities, Mash adds. 

The SAAFP recommends a midterm goal of one family physician at every district hospital, community health centre or subdistrict. 

To achieve this, says Mash, another 400 family physicians are needed, but at current training rates this could take up to two decades (not accounting for the current shortage of posts). 

He agrees with public health medicine specialist Tracey Naledi that only when there’s wider and stronger investment in primary health care across provinces will better deployment of family medicine practitioners begin to make a real difference to district level health and wellness. Naledi is associate professor in public health medicine and deputy dean of social accountability and health systems at UCT’s faculty of health sciences. 

Naledi says that while there are many highly skilled veteran “utility” medical officers in the district health system, the greater utility of family medicine is in clinical governance, health systems strengthening initiatives and capacity development. Besides teaching, monitoring, and evaluating health-care delivery, she says family physicians also more appropriately and timeously refer patients to secondary and tertiary care. 

Specialist support 

“The family physicians should not just be seeing 60 patients at their door daily. They are specialist support — the medical officers should be calling them for advice. If family physicians were optimised, we’d see far less referral to tertiary level services,” she says. 

The problem is structural, she believes. 

“There are not enough human resources for health in general, so at district level people get pulled into doing what’s needed on the shop floor. There’s not enough time to do the strategic work. 

“You can’t just talk about family medicine without talking about full staff requirements. When a family physician goes on outreach, it should not just be about dealing with difficult cases but building the capacity of the outlying areas. They need to ask themselves what they’re leaving behind. Otherwise, you’re cleaning the floor but not closing the tap,” Naledi says. 

Mash agrees that family medicine practitioners are “not the magic bullet — but introducing them into district health services can go quite a way towards strengthening the system”. 

He says: “We’ve trained them to work independently, to be the senior clinician with the full spectrum of needed skills, on top of which they provide the confidence for the doctors who are there to practise the skills they have. It’s very reassuring having a senior person to help if things go wrong, so it’s a combination of increased confidence and bringing in additional skills. 

“A primary health nurse and community health worker can provide coverage and connection to the community, but a [family medicine] practitioner brings in a level of expertise so the team has both coverage and quality.” 

We’ve trained them to work independently, to be the senior clinician with the full spectrum of needed skills
Bob Mash

History and training 

As Mash tells it, from the 1990s into the first decade of the 2000s, no medical schools exposed undergraduates to family medicine. However, nearly 30 years on, curricula have completely turned around. 

Mash says some 20 to 30 family medicine practitioners graduate from the 10 South African campuses every year, among the chief disincentives to the specialisation being the paucity of available posts. He says it’s critical to create more family medicine posts “if we are to attract people into that career path. If managers believe a family physician’s contribution is worthwhile, they can outmanoeuvre these restrictive budgets.” 

He says public health is being “hugely damaged” by an austerity mindset. 

Prof Shabir Moosa, family physician in the department of family medicine at Wits University, suggests offering a two-year distance learning diploma in family medicine to get family medicine practitioners into practice faster and then offering in-service further tuition to a full postgraduate degree. Moosa is a former president of the World Organization of Family Doctors Africa region. 

“Right now, you have family physicians in community health-care centres who see a thousand people a day. Their job is capacity building, but they’re stuck with menial tasks. Also, right now qualified family medicine practitioners, at Wits at least, have a 30% teaching commitment so they’re being pulled in many different directions.” 

Like Mash, he says “turnstile leadership” in the provinces wrecked progress while leadership in primary health care at district and lower levels is mainly by nurses, who are uncomfortable sharing space with family physicians whom they see as a “power threat”. 

Moosa says most family medicine practitioners in rural South Africa (with the exception of the Western Cape), are foreign qualified doctors who found studying it an “easy entrance route”. He takes issue with the emphasis on training family physicians exclusively for use in rural areas, saying that with accelerating urbanisation, this is short-sighted. 

Parallel with clinical associates 

Associate professor Tasleem Ras, president of the SAAFP and postgraduate programme director of family medicine at UCT, draws a parallel with clinical associates, which some provinces have adopted and others not, saying they have no career pathways, which has become “a political hot potato”. (Spotlight previously reported under the underutilisation of clinical associates here and here.) 

Ras is alluding to the provincially disparate usage of both categories of health-care professionals. In the case of family physicians at least, senior medical officer and registrar posts are being creatively used by some provinces to place them, with salary adjustments built in. Clinical associates have no such luxury. 

Naledi says she suspects that health-care delivery leaders in individual provinces have widely differing views on how to use family physicians, with commensurately differing patient care outcomes. She says the grading of health-care facilities by the Office of Healthcare Standards Compliance eloquently illustrates an overemphasis on curative service-based funding, with lower-level primary health-care facilities scoring worst, followed by secondary or district hospitals with tertiary hospitals scoring the highest. Unless this changes, she says “we will continue failing to get bang for buck”. 

She adds: “If you look at the district health system, it doesn’t have the full cadre of staff. I mean, palliative care, mental health, dental services — these are all structural and broader resource issues for me. You can’t look at family medicine in isolation.” 

The argument is that building more capacity for prevention and health promotion would begin to dismantle a self-perpetuating cycle of predominantly curative services. Family medicine training, Naledi says, focuses a lot more on the social determinants of health, prevention, rehabilitation, and palliative care. “It’s not just about clinical abilities but about them being family and community doctors,” she adds. 

* This article was first published by Spotlight — health journalism in the public interest. Sign up to the Spotlight newsletter. 

subscribe Support our award-winning journalism. The Premium package (digital only) is R30 for the first month and thereafter you pay R129 p/m now ad-free for all subscribers.
Subscribe now

Would you like to comment on this article?
Sign up (it's quick and free) or sign in now.

Speech Bubbles

Please read our Comment Policy before commenting.