​South Africa's healthcare system is in the midst of multiple changes.

It has to expand access in a skewed system that has historically favoured urban over rural and wealthy over poor, while simultaneously transforming from a hospital- and specialist-centred approach to a patient-centred one in which primary and community-based healthcare is the cornerstone of high-quality, comprehensive medical care.

“In the 1990s people basically just spoke about infrastructure and basic resources," explains Prof Bob Mash, Head of the Division of Family Medicine in the Faculty of Medicine and Health Sciences (FMHS). “When we in family medicine came along and talked about being patient-centred, people literally laughed at us. They said it was wishy-washy nonsense.

“If you read the Department of Health's Vision 2030 (its strategy document), you'll see it has now placed patient-centredness at the heart of its policy. This is a huge turnaround that requires us to improve the quality of what we're doing, think about the patient experience and listen to what patients need and want. For this thinking to percolate down into your local clinic is, however, a slow process."

The healthcare system must also be responsive to a population in which problems typical of a developing country (TB and HIV, maternal and infant deaths and illness, and interpersonal violence and injury), coexist with those more typical of developed countries (non-communicable diseases such as diabetes, cancers and other age- and lifestyle-related conditions).

Dealing with this burden of disease in mostly resource-poor environments, requires healthcare professionals with skills that have not traditionally been considered important in South African healthcare training. Instead of basic healthcare training only being viewed as a springboard to specialisation, medical graduates also need to become skilled generalists, to take the lead and provide guidance to colleagues in multi-disciplinary district healthcare teams.

An added challenge is the pending implementation of the National Health Insurance (NHI). It is the cornerstone of Health Minister Aaron Motsoaledi's plan to halt runaway cost increases in the private healthcare sector, improve access, quality and efficiency in the public healthcare sector, while also providing a basket of quality healthcare services to all South Africans, regardless of income and location.

This is likely to be a lengthy process which will pose considerable challenges to both public and private healthcare, Mash says. In its submission to the Department of Health on the NHI White Paper, the FMHS's Centre for Health Systems and Services Research warns of significant legislative, human resource, logistical, training, compliance and management challenges ahead.

Hence prospective doctors, allied healthcare professionals and healthcare managers must be able to perform to a high standard in uncertain, changing circumstances.

Excellence, everywhere

“In the next 10 to 15 years the country is meant to move into a transformed health system with primary healthcare as its main focus," Mash says. We're moving away from the African tradition of seeing primary healthcare as something for poorly trained health workers in low-cost outposts for the rural poor, to saying that primary healthcare is actually the cornerstone of the healthcare system.

“We know from research done in other countries, particularly in the USA, that health indicators are correlated with the supply of generalist doctors. Therefore, there is evidence to suggest that strong primary healthcare supported by well-trained generalists actually works. This half-hearted, watered-down, thin gruel of primary healthcare we see in many countries doesn't work."

Currently 80% of South Africans visiting primary health clinics are seen by a nurse. Research has shown that mental health and psychosocial problems are not picked up by this system.

“There is a need for more input from doctors in the primary care system if we're ever going to get to high-quality primary healthcare. It's not that the nurse must go, but there needs to be a stronger team.

“In my opinion the doctor of the future needs to be trained more consciously as a basic generalist. We need to find a way of encouraging more people to train as family physicians after they qualify in order to support the transformation of the healthcare system in the direction of strong primary healthcare. That will make a difference to the health of all South Africans."

Mash stresses the importance of teamwork in this context, where doctors work alongside nurses, psychologists, physiotherapists, occupational therapists and other allied healthcare professionals.

“Primary care is recognised as a complex field, because people are coming to you as whole persons with problems that are not yet defined. Their problems often consist of a mixture of medical, psychological and social issues, and making sense of that requires a particular skills set."

These requirements have training implications at both undergraduate and postgraduate level, much of which has been anticipated by the FMHS over the past two decades. Mash's division was the first to introduce medical students to primary healthcare by way of a two-week exposure to clinics.

“In 1997 we started taking medical students to Khayelitsha, and we had their parents phoning in horror. Over the years we've now transformed the programme to the point where we have 13 clinical rotations in family medicine, exposing medical students to primary healthcare and family medicine. We also have the rural clinical school (in Worcester). We are putting a lot of effort into exposing students to rural as well as urban health needs, and community-based education has become quite a central part of the curriculum."

He believes that basic healthcare training should evolve even further, to the point where generalism in healthcare is at the heart of the undergraduate curriculum.

Career path

Mash also believes there should be a concerted effort to promote primary healthcare and family medicine as a viable and respectable career.

“There has been a perception that if you want to be a real doctor you should become a hospital specialist, like a surgeon, chiefly because that has traditionally been the only exposure medical students got at undergraduate level. If you are only exposed to specialists, how would you imagine that there's something else worth doing?

“In addition, until recently a very solid career path for generalists in South Africa has been lacking. Now a family physician is getting paid at the same rate as other specialists, therefore it becomes attractive in the public sector. In the private sector, legally family physicians should be reimbursed at a slightly higher rate, but it hasn't really been implemented yet.

“There is a lot of interest in family medicine in the private sector, because funders need to know whether general practitioners can do what they need them to do. If someone has successfully completed four years of training specialising in family medicine, you know they are competent to do a certain number of things well. Both the four-year specialisation diploma and the two-year primary healthcare diploma enable funders to say: We will give you preferred provider status because we trust that you can do what we need you to do."

Another pertinent challenge is equipping existing doctors with the skills to meet the changing demands of the South African healthcare system.

“There are currently 18 000 doctors on the register who are not specialists, but virtually none of them have had any postgraduate training to be generalists. They are going to be the doctors in the system. There are less than 1 000 family physicians on the register. The implication is that we need to equip those 18 000 generalist doctors with the skills set they need to support a primary care system.

“We (at the FMHS) have led a national process to design a diploma for primary care doctors, which should eventually be offered by every university in the country. In 2016 we initiated this at four universities, namely Cape Town, Stellenbosch, Pretoria and KwaZulu-Natal."

Futureproof leaders

Both Mash and Prof Lilian Dudley, who heads the Community Health Division and the FMHS Centre for Health Systems and Services Research and Development (CH SSRD), point to serious leadership deficiencies in key positions at district or sub-district facilities.

“Often people are promoted into managerial positions without the managerial skills set they need. You need quite competent people at that level to really transform the system," Mash explains. “It is often healthcare workers who apply to become the CEO of a hospital. That means you are appointing a nurse, an occupational therapist, a physiotherapist or a social worker. Their professional background has not prepared them to be the CEO of a highly complicated organisation, but they are now responsible for HR, infrastructure, supply chain and strategic planning."

Dudley says the implementation of the NHI will most likely add to the complexities of healthcare management, as it would involve contracting services from both the public and the private sector.

“The Minister of Health has recognised that quality hospitals need managers who are properly qualified in medicine and management. However, there are very few programmes to train managers, and in practice the person who has been there the longest tends to get promoted."

Dudley and her colleagues at the CH SSRD have developed a postgraduate diploma in healthcare management aimed specifically at individuals who are already employed in senior healthcare management positions. Based on extensive research, it offers 11 applied modules, including project and operations management, financial governance, health technology and quality improvement.

“We encourage candidates with experience to enrol and we expect them to apply the theory taught in the classroom in the workplace," she says.

“We need managers and leaders with a more transformative and collaborative style of leadership," Mash concludes. “It is hard to help people make that transition if, while growing up, they never experienced anything but command and control, often in an extreme form."

Caption: Profs Lilian Dudley and Bob Mash

Photos: Damien Schumann & Stefan Els