Evaluating the impact of family physicians within the district health system of South Africa

Thesis (D.Phil)--Stellenbosch University, 2017.ENGLISH SUMMARY: The majority of the South African population are dependent on the public health sector in helping them deal with the quadruple burden of disease, consisting of HIV/AIDS and tuberculosis, maternal and child health problems, non-communicable diseases as well as trauma and violence-related injuries. The post-1994 South African government has embraced the global shift towards primary health care (PHC) as the vehicle for delivering quality health care to all. The health of communities is better in countries with strong PHC-centred health systems. Global evidence supports PHC delivered by primary care teams that include doctors with postgraduate training in family medicine (family physicians). However, the evidence on the contribution of family physicians (FPs) to strengthening health systems is mainly derived from high income countries. African leaders and policy makers are looking for local evidence on the potential role of FPs, as investment in the training and development of a new cadre of specialists in family medicine represents a significant financial commitment within the health system. According to a 2015 national consensus paper, South African FPs have six roles in the PHC team: care provider to patients, consultant to the PHC team (mainly nurses and doctors), champion of community-oriented PHC, clinical governance leader (focus on quality improvement), clinical trainer of students and registrars, and capacity building of the PHC team members. FPs are working in various aspects of the South African district health system (DHS), namely district hospitals, primary care facilities (health centres and clinics) and community based PHC teams (community health workers). The DHS consists of all health services relating to the health and wellbeing of a community within a defined geographic area (the health district). The discipline of family medicine was made a specialty in 2007 by the South African health professions council and resulted in re-structured training of FPs in keeping with the training model of other medical specialities. Graduates from this new training model have entered the DHS since 2011. These graduates are deployed in a heterogeneous manner in the different provinces, which reflect the uncertainty among policy makers and health managers on how best to use FPs in their districts. FPs represent a costly human resource investment in an environment dominated by vertical disease programmes and nurse-driven PHC services. This uncertainty together with the paucity of local evidence paved the way for anational study that was conceptualised in response to a joint funding call of the National Department of Health and EuropeAid in 2013, titled: “Strengthening primary health care through primary care doctors and family physicians”. This PhD research project represents one component of the overall project that aimed to evaluate the contribution of FPs to the DHS in South Africa. The study aimed to evaluate the impact of FPs within the DHS of South Africa. The study objectives are shown below: A. To describe the perceived impact of FPs in terms of their six roles within the DHS. B. To describe co-health workers’ perception of the impact of FPs compared to medical officers who had received no postgraduate training. C. To compare the perceived impact of FPs between metropolitan and rural districts, between facility types (district hospitals vs. primary care facilities), as well as by training programme model (graduation before and after 2011). D. To explore the perceptions of district managers regarding the impact of FPs in the following three domains: health system performance, clinical processes and health outcomes. E. To assess the influence of FPs at primary care facilities and district hospitals. The influence of FPs was evaluated in terms of two domains: health system performance, and quality of clinical processes across the burden of disease. F. To evaluate the impact of an increase in FP supply in each district (number per 10 000 population) on key health system performance indicators, key clinical processes and key health outcomes.AFRIKAANS OPSOMMING: Die meeste Suid-Afrikaners is afhanklik van die publieke gesondheidsorgsektor om hul viervoudige siektelas aan te spreek, wat MIV/VIGS en tuberkulose, moeder- en kindergesondheidsprobleme, nie-oordraagbare chroniese siektes, sowel as trauma en geweld-verwante beserings, insluit. Die post-1994 Suid-Afrikaanse regering het die wêreldwye verskuiwing na die klem op primêre gesondheidsorg (PGS) aanvaar as die meganisme om gehalte gesondheidsorg aan die hele bevolking te bied. Gemeenskappe se gesondheid is beter in lande met sterk PGS-gesentreerde gesondheidstelsels. Internasionale navorsing ondersteun PGS verskaf deur primêre gesondheidsorgspanne, wat dokters insluit met ‘n nagraadse opleiding in huisartskunde (huisartse). Die navorsingsbevindinge rakende die bydrae van huisartse tot die verbetering van gesondheidstelsels kom egter hoofsaaklik vanuit hoë-inkomste lande. Afrika-leiers en -beleidmakers is op soek na plaaslike bewyse rakende die potensiële rol van huisartse, aangesien die belegging in die opleiding en ontwikkeling van hierdie spesialiste in huisartskunde 'n beduidende finansiële belegging vir die gesondheidstelsel verteenwoordig. Volgens 'n 2015 nasionale konsensus dokument, vertolk Suid-Afrikaanse huisartse ses rolle in die PGS-span, naamlik: klinikus, konsultant vir die PGS-spanlede (hoofsaaklik verpleegsters en dokters), voorstander van gemeenskapsgeoriënteerde PGS, kliniese leier (met ‘n fokus op kwaliteit verbetering), kliniese opleier van studente en kliniese assistent, en kapasiteitsbou van die PGS-spanlede. Huiartse is werksaam in verskeie aspekte van die Suid-Afrikaanse distriksgesondheidstelsel (DGS), naamlik distrikshospitale, primêre gesondheidsorgfasiliteite (daghospitale en klinieke) en gemeenskapsgebaseerde PGS-spanne (gemeenskapsgesondheidswerkers). Die DGS bestaan uit alle gesondheidsdienste wat verband hou met die gesondheid en welsyn van 'n gemeenskap binne 'n bepaalde geografiese gebied (die gesondheidsdistrik). Die huisartskunde dissipline is in 2007 deur die Suid-Afrikaanse Raad vir Gesondheidsberoepe as 'n nuwe spesialiteit aanvaar. Dit het gelei tot 'n hersiene nagraadse opleidingsprogram vir huisartse in ooreenstemming met die opleidingsmodel van ander mediese spesialiteitsrigtings. Afgestudeerdes van hierdie nuwe opleidingsmodel is sedert 2011 in die DGS werksaam. Hierdie afgestudeerdes word egter op verskeie wyses in die Stellenbosch University https://scholar.sun.ac.za xi verskillende provinsies aangestel, wat ‘n weerspieëling is van die mate van onsekerheid onder beleidmakers en gesondheidsbestuurders rakende die beste wyse om huisartse in hul distrikte aan te wend. Huisartse verteenwoordig 'n duur menslike hulpbronbelegging in 'n omgewing wat oorheers word deur vertikale siekteprogramme en verpleegdiensgedrewe PGS-dienste. Hierdie onsekerheid, tesame met die gebrek aan plaaslike navorsingsbevindinge, het die weg gebaan vir 'n nasionale studie, wat gekonseptualiseer is in reaksie op 'n gesamentlike befondsingsgeleentheid verskaf deur die Nasionale Departement van Gesondheid en EuropeAid in 2013, getiteld: "Die versterking van primêre gesondheidsorg deur primêre sorg dokters en huisartse". Hierdie PhD-navorsingsprojek verteenwoordig een gedeelte van die algehele projek wat daarop gemik was om die bydrae van huisartse in die DGS in Suid-Afrika na te vors. Die studie het ten doel om die impak van huisartse binne die DGS van Suid-Afrika te evalueer. Die studie doelwitte was as volg: A. Om die waargenome impak van huisartse te beskryf in terme van hul ses rolle binne die DGS. B. Om mede-gesondheidswerkers se ervaring van die impak van huisartse te beskryf in vergelyking met mediese beamptes sonder nagraadse opleiding. C. Die vergelyking van die waargenome impak van huisartse tussen metropolitaanse en landelike distrikte, tussen fasiliteits-tipes (distrikshospitale teenoor primêre gesondheidsorgfasiliteite), sowel as opleidingsmodel (afgestudeer voor en na 2011). D. Om die ervaring van distriksbestuurders rakende die impak van huisartse in die volgende drie areas te ondersoek: gesondheidsorgstelsel funksionering, kliniese prosesse en gesondheids uitkomste. E. Om die invloed van huisartse in primêre gesondheidsorgfasiliteite en distrikshospitale te evalueer. Die invloed van huisartse is geëvalueer in terme van twee domeine: gesondheidstelsel funksionering en die kwaliteit van kliniese prosesse. F. Om die impak van 'n toename in huisartsgetalle in elke distrik (getal per 10 000 bevolking) te evalueer op sleutel gesondheidsorg prestasie-aanwysers, sleutel kliniese prosesse en sleutel gesondheidsuitkomste