“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 80% of their population covered, including vast urban areas such as Sao Paulo and Rio de Janeiro,” he said.
In South Africa’s case, having a family physician as the leader will further enhance the model.
Mash said South Africa’s previous health policies saw family physicians as a sub-specialty of internal medicine or as specialists who should work at tertiary hospitals and within primary care teams. Chiefly due to the lack of posts, only a third of family medicine graduates were retained in the public sector, with 10% emigrating and 11% giving up medicine altogether. Most were employed in the Western Cape, where the health system had committed to appointing family medicine practitioners at district hospitals and primary care facilities, Mash said.
The SAAFP recommends a mid-term goal of one family physician at every district hospital, community health centre or sub-district.
To achieve this, said Mash, another 400 family physicians are needed, but at training rates this could take up to two decades, (not accounting for the shortage of posts).
He agreed 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 said 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 said family physicians also more appropriately and timeously refer patients to secondary and tertiary care.
“The family physicians should not only 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 said.
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,” she said.
“You can’t talk about family medicine without talking about full staff requirements. When a family physician goes on outreach, it should not only 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,” she said.