The contribution of family physicians to district health services: a position paper for the National Department of Health

1. Introduction

This document has been prepared for the National Department of Health at the request of Dr Terence Carter and Ms Jeanette Hunter following a round table meeting between them and Professors Naidoo, Hellenberg and Mash who represented the discipline of Family Medicine – the South African Academy of Family Physicians and the College of Family Physicians.

It was clear from the meeting that the discipline of Family Medicine has a number of problems in realising the contribution of Family Physicians to strengthening district health services in South Africa. The purpose of this document is to provide a comprehensive overview of their contribution to the health system and to outline the issues that need attention.

2. Policy context

2.1 International

The World Health Organization has noted that “physicians with a specialization in family medicine or general practice” are usually an essential part of effective approaches to primary care.(1)

The World Health Assembly has also recommended that “[we need] to train and retain adequate numbers of health workers, with appropriate skill-mix, including primary health care nurses, midwives, allied health professionals and family physicians, able to work in a multidisciplinary context, in cooperation with non-professional community health workers in order to respond effectively to people’s health needs”.(2)

The Africa Region of the World Organization of Family Doctors (WONCA) has published a consensus statement on the contribution of family medicine and role of the family physician in the African context.(3)

2.2 National

In South Africa the National Development Plan specifically recognises the important role that family physicians should play in clinical governance and improving the quality of district health services. The Plan also notes that family physicians who are trained across multiple “specialist areas” can offer useful clinical leadership in the health districts.(4)

The plans for National Health Insurance and the re-engineering of primary care envisage a role for the family physician at district hospitals and as part of district clinical specialist teams, but are less clear about their role in relation to primary care and community-based services (ward-based outreach teams).(5)

The national Human Resources for Health policy suggests that we should aim for 0.2 family physicians per 10 000 population, which implies a total of 1060 family physicians for the country. Currently there are 545 family physicians on the new HPCSA family physician register (initiated when the discipline was formally recognised as a speciality in 2007) and a further 525 remain on the old family physician register. It is not possible to determine how many of these are in public or private practice or overseas.(6) The discipline of family medicine, in its response to the draft Human Resources for Health policy, also questioned some of the underlying assumptions made when setting this target. For example the document (NDoH Health Workforce Model Annexure B) appeared to consider family medicine as a sub-speciality of medicine in a referral hospital setting rather than a generalist discipline in the district health services – this resulted in conclusions such as the target for ophthalmologists (0.5 per 10 000 population) being more than twice that for family physicians. The SA Academy of Family Physicians has previously worked on a ratio of 1 family physician per 10 000 population as a goal.

3. Health and health services context

It is widely recognised that South Africa has a heavy quadruple burden of disease that can be described in terms of HIV/AIDS and TB, maternal and child health, injuries and violence, and non-communicable chronic diseases.(7)

Community-based services are currently poorly developed with pockets of innovation and excellence. The re-engineering of primary health care strives for more universal coverage through ward-based outreach teams (WBOTs) that are responsible for geographically defined households and which can also transform the health system to be more pro-active, preventive and promotive.(5) There are encouraging examples of early success, such as in the City of Tshwane where the establishment of WBOTs is being championed by the Department of Family Medicine at the University of Pretoria.(8,9)

Primary care services at clinics and community health centres are struggling to cope with high patient numbers, the complexity of undifferentiated problems, multi/co-morbidity and serious illness. Eighty percent of consultations are with primary care nurses who have relatively brief training to cope with this complexity and the breadth of morbidity seen.(10) Despite their best attempts primary care is not yet delivering a quality service that is characterised by adequate access, continuity, co-ordination, comprehensiveness and efficiency. There is also little chance for or emphasis on health promotion and disease prevention, which are seen as separate activities or programmes, and not integrated into the clinical service. There have been significant successes with certain vertical programmes, such as for HIV/AIDS, but these improvements are not systematic

Non-communicable diseases currently dominate the consultation room in much of ambulatory primary care, but these are mostly very poorly managed, with a failure to adhere to guidelines, and often the focus is on re-prescribing medication rather than on comprehensive management of chronic illnesses and prevention of complications.(11) Clinical care also appears to lack a bio-psycho-social approach as, for example, conditions such as depression and anxiety, which are known to be common, go unrecognised, and other mental health problems are poorly managed.(12) The need for services to be more patient-centred is also clear.

District hospitals have been shown to lack the ability to provide essential services, for example in the arena of emergency obstetric care.(13) In the Western Cape the skills gap identified at district hospitals was one of the main reasons that the Department of Health saw a need for family physicians.(14)

At the district level the National Department of Health has introduced District Clinical Specialist Teams as an initiative intended to improve maternal and child health care.(5) This team includes a family physician as one of the designated specialists.

4. Contribution of family physicians

Family physicians are expert generalists who have successfully completed postgraduate training in family medicine.

This postgraduate training is organised on the same basis as specialists – a full time 4-year MMed programme, with supervised clinical training in registrar posts, and a single national exit exam organised by the Colleges of Medicine. On graduation family physicians are registered at the HPCSA in a separate register, in the same way as specialists, and are employed in posts on the same specialist rank.

4.1 Roles of the family physician

The discipline of family medicine has agreed nationally that the contribution of family physicians can be defined in terms of six key roles (Figure 1).(15)

 

Figure 1: Six roles of the family physician

4.1.1 Care provider

The family physician is primarily a clinician who has been trained to care for the majority of problems encountered at both district hospital and in primary care. Their training stretches across multiple clinical domains, as far as they relate to the services provided and competencies required within the district health services. These 10 clinical domains have been described as shown in Figure 2.(15) The clinical skills for this have also been defined in detail nationally(16); but would include, for example, the ability to perform emergency obstetric care, general anaesthesia, primary and secondary surveys of trauma patients, closed reductions and immobilisation of fractures, intra-osseous access, fine needle aspiration biopsy, interpretation of radiographs and brief behaviour change counselling.

 

Figure 2: Clinical domains included in the training of family physicians

Their training also embraces the key attributes of an expert generalist: (17,18)

“Medical generalism is an approach to the delivery of health care that routinely applies a broad and holistic perspective to the patient’s problems. Its principles will be needed wherever and whenever people receive care and advice about their health and wellbeing, and all healthcare professionals need to value and be able to draw on this approach when appropriate. The ability to practise as a generalist depends on one’s training, and on the routine use of skills that helps people to understand and live with their illnesses and disabilities, as well as helping them to get the best out of the healthcare options that are available and appropriate for their needs.

It involves:

a) Seeing the person as a whole and in the context of his or her family and wider social environment

b) Using this perspective as part of one’s clinical method and therapeutic approach to all clinical encounters

c) Being able to deal with undifferentiated illness and the widest range of patients and conditions

d) In the context of primary care, taking continuity of responsibility for people’s care across many disease episodes and over time

e) Also in primary care, coordinating his or her care as needed across organisations within and between health and social care.”

4.1.2 Consultant

Although family physicians are trained for primary care the current nurse-led primary care system often places them in more of a consultant role in relation to primary care nurses and other members of the primary care team. As the clinician with the most advanced training it is expected that they will see patients with more complicated problems that are referred to them.

Even at the district hospital the family physician is often the most highly trained member of the clinical team, although there may well be experienced career medical officers in certain areas of the hospital. Again the family physician can act as a consultant to more junior team members such as interns, community service medical officers and clinical associates.

4.1.3 Capacity builder

One of their key roles is that of a clinician with the necessary knowledge, skills and attitudes to serve as a role model and a resource to the primary care team. They would therefore spend time mentoring and building capability amongst other members of the team such as community health workers, primary care nurses, clinical associates and junior medical officers. Sharing their expertise through role-modelling, mentoring, consulting and continuing professional development is seen as a key role, and is part of the training for family medicine registrars.

4.1.4 Supervisor

In certain training facilities the family physician may also take on specific responsibility for the clinical training and supervision of undergraduate (medical and clinical associate students) and postgraduate students (registrars) as well as interns. For this they will need additional expertise in teaching, training and assessment.

4.1.5 Manager

Clinical governance with the intention of improving the quality of clinical care is a key role expected of family physicians and they are expected to have expertise in quality improvement cycles, risk management meetings, implementation of guidelines, evidence-based practice, research and training. They should be “change agents” in the system and offer significant leadership to help take the health services forwards.

They are not expected to take responsibility for other traditional management activities such as managing human resources, infrastructure and finances. Although this is not seen as their responsibility they will often contribute to these issues as senior clinicians and as part of the leadership within the facility.

4.1.6 Champion of community-orientated primary care

In addition to focusing on the needs of individual patients, family physicians are expected to champion an awareness of the population at risk and the community served by the health facility. Patients are assessed and managed within the context of their families and communities, and family physicians will often take the initiative to support or develop community-based health programmes to address common problems seen. In practice this may mean making sense of community health needs and priorities, supporting the functioning of WBOTs or helping to plan interventions to address community health needs. The development of and research into the implementation of WBOTs is of particular importance at this time. Family physicians are well placed to participate in developing these teams as a quality service and especially in integrating them into a seamless continuation of care from home, clinic, hospital and back.

4.1.7 Role differentiation and maturation

It may be a lot to expect that a newly qualified family physician would fulfil completely all the roles outlined above. In reality our experience is that some role differentiation does occur once family physicians are in place. For example where two family physicians are employed in a sub-district one may focus more on supporting the primary care platform and community orientated primary care, while the other focuses on care within the district hospital. Similarly one may focus almost entirely on service delivery, while the other also takes on the formal supervision and training of students and interns. In large district hospitals family physicians may also take responsibility for specific areas of the hospital, while retaining a generalist stance across all areas after hours.

The family physician’s role in management also seems to shift over time as they gain experience and seniority. Newly qualified family physicians (grade 1 specialists) focus more on clinical work and immediate clinical governance issues, while more senior family physicians (grade 2-3 specialists) tend to take on more of a role as a clinical manager or even a training complex co-ordinator, as well as contributing to sub-district and district management teams.

4.2 Role clarification

This section discusses the role of the family physician in relation to other members of the health care team.

4.2.1 Community health workers and ward-based outreach teams

WBOTs are envisaged as consisting of groups of community health workers supported and supervised by nursing staff, usually from the local clinic. In addition there is a need for primary care doctors to assist the teams with capacity building, making sense of information gathered and planning effective responses, as has been demonstrated in the City of Tshwane. Community-orientated primary care requires input from this level of expertise for it to be successful. Family physicians can make a useful contribution by helping to guide and co-ordinate multiple WBOTs at the sub-district level, again as modelled in the City of Tshwane.

4.2.2 Primary care nurses

Primary care nurses are currently the backbone of a nurse-driven primary care service as they offer the majority (80%) of first contact care. As has been stated above they may struggle to provide the quality of generalist care required given the breadth, complexity and undifferentiated nature of the problems presenting to them. Family physicians can be instrumental in improving their capacity and the quality of care.

4.2.3 Clinical associates

Clinical associates have been trained to assist with clinical care in the district hospital. Family physicians champion the integration of the clinical associates into the health service. The family physician in the district hospital would be involved with training, mentoring and supervising them, as well as promoting their role in the healthcare team.

4.2.4 Primary care doctors

There are thousands of primary care doctors in the country who are already in the health system and working as either medical officers in the public sector or general practitioners in the private sector. Primary care doctors are not required to have any additional training after their undergraduate degree, although some undertake Diplomas and short courses. The different competencies of primary care doctors are therefore highly variable.

Junior medical officers in the public sector should be encouraged to apply for registrar posts and train as family physicians if they decide to pursue a career in the district health system. Established senior medical officers or general practitioners, who will most likely not pursue further training to become family physicians, should be encouraged at least to obtain a Postgraduate Diploma in Family Medicine and Primary Care. Family physicians in this context would, in the near future, most likely be placed at community health centres where they would offer their clinical expertise and leadership to the team, including the other primary care doctors.

Family physicians can also enter the private sector although their additional training and equivalent specialist status is not yet fully recognised by funders, which is a factor in making the career path unattractive to many doctors.

The 2-year Diploma in Family Medicine and Primary Care is currently being revised at a national level to align itself better with the future direction of the health system and to help primary care doctors re-orientate and up-skill themselves. The roles of the primary care doctor that are envisaged echo those of the family physician, but are limited to the primary care setting and there are lower expectations of the primary care doctor than the family physician. The future roles that have been conceptualised are: competent clinician, critical thinker, capability builder, collaborator, change agent and community advocate.

4.2.5 Medical officers in district hospitals

Family physicians employed at the district hospital are expected to be competent across the full package of care and to be able to lead the rest of the team in delivering on this. In some district hospitals the medical officer establishment is very small and junior, and the family physician brings a new level of clinical expertise and leadership. In other district hospitals there are existing career medical officers who may be very competent in specific clinical areas, sometimes even more so than the newly qualified family physician. In the long term view however the family physician would become the most senior clinician at the district hospital and would also bring their additional roles to bear in terms of capacity building, supervision, clinical governance and community orientation.

4.2.6 Facility and district managers

Family physicians are not intended to take the place of facility managers or chief executive officers. As the most senior clinician in the facility they would work closely with the manager to improve the quality of care and efficiency of the health services. It may be that in some instances a qualified family physician will be employed in this role. In larger district hospitals a clinical manager may be appointed to manage the clinical services under the chief executive officer. In this scenario the role of clinical manager and that of a more senior family physician have the potential to overlap considerably.

4.2.7 District clinical specialist teams

Family physicians, in conjunction with the other specialists and team members, have been appointed as members of the DCSTs. The DCSTs were established with a specific focus on improving maternal and child healthcare at a district level. Family physicians are important members of the teams to enable an effective engagement with the district. However, it will be clear from the above discussion that being members of the DCST is not considered the main role of the family physician in the district health services – the majority should rather be located clinically within the district health services themselves, and not just at the level of the district in the DCST. This also implies having many family physicians per district, typically employed at sub-districts, community health centres or district hospitals Their training as expert generalists is also incongruent with a specific focus on only maternal and child healthcare.

4.2.8 Public health specialists

Public health specialists and family physicians have very different but complementary roles in the district. The family physician is primarily a clinician who works with the community-based, primary care and district hospital teams to provide high quality clinical care for individual patients. The public health specialist brings expertise in epidemiology, community health, health policy, health information and management from a population perspective and at a district level.

Community-orientated primary care is a bridge between the family physician and public health specialist as it is in this role that they are required to think about the population at risk as a whole and the health needs of households at a community level.

4.2.9 Emergency medicine specialists

Emergency Medicine is a new speciality in South Africa that has emerged at much the same time as Family Medicine. Emergency medicine specialists clearly have a role in providing care and clinical leadership within dedicated trauma and emergency centres with a sufficient workload. Emergency medicine specialists have a clear and separate role from the family physician at central, tertiary and regional hospitals (although there are still examples of family physicians leading emergency departments in regional hospitals). At large district hospitals, particularly in urban areas, there may also be a place for the emergency medicine specialist to work alongside the family physician and take responsibility for the emergency centre. In smaller and more rural district hospitals and community health centres the family physician takes responsibility for emergency care.

4.2.10 Other medical specialists

By and large the other medical specialists are located within central, tertiary and regional hospitals, where there is little overlap with the role of the family physician. Some regional hospitals have created family medicine departments to focus on district type services offered within the regional hospital, but the natural habitat of family physicians is within the district. In addition some large district hospitals, especially in urban areas, that offer services above the norm for district hospitals, also employ other specialists alongside the family physician. Generally speaking, however, other medical specialists are not employed within the district health services. Their role is within the DCSTs or in performing outreach and support from the regional hospitals.

Family physicians play an important role to integrate care from other medical specialists into the district. They collaborate with the other medical specialists to ensure coordination of patient care between levels of the health system and that their knowledge and expertise becomes available where appropriate to the district services. 

Early evidence of impact

Family physicians from the new registrar training programmes only started graduating in 2011 and so it is early days to evaluate their impact. Nevertheless some initial research has been conducted in the Western Cape, which has included the deployment of family physicians as part of its strategic planning for some time.  The number of family physicians has increased from 21 in 2011 to 45 in 2014 within the district health services – at both district hospitals and community health centres.

Annual interviews with the district managers in 2012 and 2013 have suggested that family physicians have had a positive impact on the quality of clinical processes with specific examples given for HIV/AIDS, TB, maternal and child health, non-communicable diseases and mental health.(19) In addition they appear to have had some impact on health services performance in terms of improved access to care, better co-ordination, more comprehensive and efficient services.

In the Winelands and Overberg Districts one of the registrars has developed and piloted a family physician impact assessment tool, which evaluated the family physician’s impact in terms of the 6 key roles and perspective of people working alongside them.(20) Initial results (see Figure 3) show that their main perceived contribution was in the area of clinical care, consulting patients referred to them by other members of the health care team and in clinical governance. They had a more moderate impact in terms of building the capacity of the healthcare team and in clinical training to students and registrars. Their least impact was in the area of supporting community-orientated primary care.

 

Figure 3: Impact by roles of family physicians in the Winelands and Overberg Districts (High impact > 3.5, moderate impact 3.0-3.4, low impact < 3.0) –research assignment, Dr K Pasio.

 

Implications for posts and career paths

Public sector posts

From the above overview of the roles and contribution of the family physician it is clear that posts should primarily be created for the family physician at:

  • The sub-district level to develop and support the WBOTs and primary care services within that sub-district. This may mean employing family physicians for all or part of a sub-district or employing a family physician at each community health centre with responsibility also for the local area served by that centre.
  • The district hospital.

We should have a short-term goal as a country of initially having one family physician employed per sub-district and district hospital.

There are 104 sub-districts with no community health centres, 321 community health centres in the remaining sub-districts and 254 district hospitals in South Africa which would therefore require 680 family physician posts to achieve this short-term goal. Given the current number of registered family physicians and the 8 training programmes, this is a feasible goal.  In terms of the WISN process for PHC this would mean including the family physician as a full time post on the normative guideline for community health centres or sub-districts.

The misunderstanding in some provinces that “specialist” family physicians cannot be deployed in the district health services needs to be dealt with. Likewise the concept that a district hospital should have a department of family medicine is also contrary to the generalist nature of the family physician who works across the whole hospital and not a section of it. Where facilities are part of training programmes for under/postgraduate students in family medicine it may also be necessary to have more than one family physician in order to ensure quality training. In large district hospitals it will be necessary to have more than one family physician to deliver the service required.

Additional posts for family physicians have also been created as part of DCSTs and in some regional hospitals that see the need for a department of family medicine. However this is not seen as the norm for deploying family physicians in the health system.

Private sector posts

The failure to fully recognise the discipline of family medicine in the private sector is a major disincentive for doctors not wanting to remain in the public sector to enter the training programmes. This recognition is not only about the tariff and remuneration, but also about the recognition of their postgraduate training and the larger skills set and competencies that they consequently bring.

Ensuring that the regulatory environment in the private sector recognises family physicians is an important goal to growing the discipline.

 

 

Career Path

The future career path for a doctor intending to commit to a career in the district health system should be one of initial experience as a junior medical officer in the district health services, followed by entry into a 4-year registrar post and qualification as a family physician, who is subsequently employed in either the public or private sector (Figure 4). In the long term this endpoint may be replaced by entry into the national health insurance scheme as a family physician. This career path should eventually replace the current concept of a career medical officer.

Existing primary care doctors who are unlikely to now train as family physicians should be encouraged to complete the Diploma in Family Medicine and Primary Care. In the future this Diploma could also be a stepping stone to training as a family physician for those unsure about whether to fully commit or who want to prepare themselves better.

 

Current training programmes

Current situation and achievements

There are currently eight training programmes for family physicians in the country offered by the medical schools at Cape Town, Stellenbosch, Free State, Witwatersrand, Pretoria, Limpopo (Medunsa), Kwa-Zulu Natal and Walter Sisulu.  Two new departments at Limpopo (Polokwane) and Nelson Mandela Metropolitan University (Port Elizabeth) are expected to become established in the near future.

These eight training programmes are co-ordinating their activities through the South African Academy of Family Physician’s Education and Training Committee (previously this was done by the Family Medicine Education Consortium FaMEC). Key successes of this collaboration are:

  • Textbooks such as the Handbook of Family Medicine and the SA Family Practice Manual.(23,24)

The College of Family Physicians currently offers a single national exit examination that all training programme participate in http://www.collegemedsa.ac.za/view_exam.aspx?examid=102

The training programmes are organised on the same principles as specialist training:

  • 4-years of clinical training in a registrar post with exposure to primary care, district hospital and regional hospital. Supervision is required from a family physician or other medical specialists in the regional hospital.
  • Enrolment in a Master of Medicine degree, which requires a research assignment
  • Final examination by the College leading to a Fellowship qualification.
  • Accreditation of training programmes and complexes by the HPCSA.

There are two professional bodies currently involved in the discipline of family medicine in South Africa. The South African Academy of Family Physicians is more focused on co-ordinating and developing education and training at a national level, represents the discipline via SAMA, offers an annual conference and a national scientific journal, and represents the discipline globally at WONCA, as well as accrediting and offering continuing professional development. The College of Family Physicians is part of the Colleges of Medicine and focuses almost entirely on the national exit examination.

 

 

Challenges of the current training programmes

The training programmes have many challenges in terms of their implementation and consolidation. In this position paper we will highlight challenges that require assistance from the NDOH.

It should be noted that at the last College exam there were only 12 new graduates from across the country. This output is of course too small a number to make a difference. Training programmes need to accelerate (at least double) their outputs if the human resource goals are to be met. It appears that family physicians have only been deployed at scale within the Western Cape where there are currently 45 family physicians employed in the public sector and 50 registrars in training.

Attracting junior doctors to enrol for a career in the district health system as family physicians requires them to experience positive role models and examples during their undergraduate and post-graduation careers. Currently many provinces do not have many family physicians in posts within the district health services and therefore the discipline remains somewhat invisible. Creating posts within the district health services and employing family physicians in these posts, as well as many existing, unfunded or unfilled posts, is critical not just for their contribution to the services, but for the success of the training programmes.

Prior to 2007 the family medicine training programmes were more part-time, less standardised and more focused on primary care than the district hospital. Most family physicians on the current register would have been trained in these previous programmes. Many of these family physicians also failed to migrate across from the old family medicine to the new specialist HPCSA register and this is currently also being discussed with the NDOH. This also means that care must be taken when employing these family physicians at district hospitals to ensure they have the correct skills set, as not all training programmes previously included this. All of them would have trained appropriately for primary care. In the Western Cape a rapid assessment team has successfully been used to evaluate the suitability of applicants from the older training programmes for work in district hospitals.

Success of the training programmes does not just depend on having a family physician in post to fulfil the HPCSA requirements (1 family physician for 4 registrars), but requires this family physician to have the capacity to provide quality clinical training. This capacity depends on the capability of the family physician (who may need additional training for this) as well as their environment. Key factors in the environment include the ability of the family physician to devote time and energy to clinical training and teaching. Often service delivery takes precedence over this and therefore it is necessary to create extra capacity by safeguarding a percentage of their time for this role. This may require having more than one family physician at the accredited training sites and placing one of them on the joint staff with the university. If a family physician is to fulfil the six roles previously described it is also important that they work with a sufficient staff complement. When, for example, there are no junior medical officers in the facility the family physician is forced to work in their place and is unable to contribute in terms of consulting, mentoring, supervision, clinical governance and COPC.

Once doctors are interested in applying for the training programmes it is necessary to have registrar posts available for them to enter. In many provinces there are very few registrar posts in family medicine and financing of such posts is not secure on an ongoing basis. Registrars are also expected to shoulder an enormous service load, which does not make the posts attractive. Family medicine has attracted interest from foreign doctors working in South Africa, but these doctors have often not performed well on the training programmes or have plans to leave the country on qualifying. There is a need when selecting registrars to focus on South African citizens and permanent residents who have a commitment to the district health system.

Key recommendations

To summarise the key recommendations that derive from the above position paper:

  1. We should have a short-term goal as a country of having initially one family physician employed per sub-district and one per district hospital.
  2. We should ensure that the regulatory environment in the private sector fully recognises family physicians as an important component of health care provision.
  3. We should ensure that family physicians working in accredited training sites have sufficient capacity to provide quality training through additional family physician posts and joint staff positions.
  4. We should ensure sufficient registrar posts are available for each training programme and that the finances for these posts are secured on an on-going basis.

References

  1. World Health Organization. The World Health Report 2008: Primary Health Care - Now more than ever. Geneva: WHO, 2008.
  2. World Health Assembly. Resolution 62.12: Primary Health Care, Including Health Systems. Geneva: 62nd World Health Assembly, 18 - 22 May 2009.
  3. Mash B, Reid S. Statement of consensus on Family Medicine in Africa.  Afr J Prm Health Care Fam Med. 2010;2(1), Art. #151, 4 pages. DOI: 10.4102/ phcfm.v2i1.151
  4. Government of South Africa. Chapter 10: Promoting Health in the National Development Plan - 2030. Pretoria: Government of South Africa; 2013:330-351
  5. National Department of Health. National Health Insurance in South Africa: Policy Paper. Pretoria: NDoH, 2011.
  6. National Department of Health. Human Resources for Health, South Africa, 2030. Pretoria: NDoH, 2011.
  7. Bradshaw D, Norman R, Schneider M. A clarion call for action based on refined DALY estimates for South Africa. S Afr Med J 2007; 97: 438–440.
  8. Bam N, Marcus T, Hugo J, Kinkel H. Conceptualizing Community Oriented Primary Care (COPC)–the Tshwane, South Africa, health post model. African Journal of Primary Health Care & Family Medicine 2013;5(1):3 pages. DOI:10.4102/phcfm.v5i1.423
  9. Kinkel H, Marcus T, Memon S, Bam N, Hugo J. Community oriented primary care in Tshwane District, South Africa: assessing the first phase of implementation. 2012;5(1): 9 pages pages. DOI:10.4102/phcfm.v5i1.477
  10. Mash B, Fairall L, Adejayan O, et al. A morbidity survey of South African primary care. PLoS ONE 2012;7(3):e32358. [http://dx.doi.org/10.1371/journal.pone.0032358]
  11. Van Deventer C, Couper I, Sondzaba N. Chronic Patient Care at North West Province Clinics. Afr J Prm Health Care & Fam Med. 2009;1(1), Art. #8. DOI:10.4102/phcfm.v1i1.8  Available from http://www.phcfm.org
  12. Van Deventer C, Couper I, Wright A, Tumbo J, Kyeyune C. Evaluation of primary mental health care in North West province – a qualitative view. SA J Psychiatry. 2008; 14 (4):  136-140.
  13. Pattinson R. ESMOE Baseline Survey of the functionality of health care facilities in 12 core districts in relation to emergency obstetric care. Presented at the 17th National Family Practitioners Conference, 2014.
  14. De Villiers M, De Villiers P. The knowledge and skills gap of medical practitioners delivering district hospital services in the Western Cape, South Africa. S Afr Fam Pract. 2006;48(2):16.
  15. Mash B. Reflections on the development of family medicine in the Western Cape: a 15-year review. S Afr Fam Pract 2011;53(6): 557-562
  16. Couper I, Mash B. Obtaining consensus on core clinical skills for training in family medicine SA Fam Pract 2008;50(6):69-73
  17. Howe A. Medical Generalism: Why Expertise in Whole Person Medicine Matters. London: RCGP, 2012. http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z-policy/Medical- Generalism-Why_expertise_in_whole_person_medicine_matters.ashx (accessed 5 November 2013).
  18. Howe AC, Mash RJ, Hugo J. Forum: Developing generalism in the South African context. South African Medical Journal 2013; 103(12): 899-900.
  19. Swanepoel M, Mash R. Assessment of the impact of family physicians in the district health system of the Western Cape, South Africa. African Journal of Primary Health Care & Family Medicine, In Press
  20. Pasio K, Mash R. Assessment of the perceived impact of family physicians in the district health system  of the Western Cape Province, South Africa [MMed thesis]. Cape Town: Stellenbosch University, 2014.
  21. Couper I, Mash B, Smith S, Schweitzer B, Outcomes for family medicine postgraduate training in South Africa. South African Family Practice Journal 2012; 54(6): 501-506
  22. College of Family Physicians. National Portfolio of Learning. Pretoria: Colleges of Medicine, 2014.
  23. Mash B (Ed). Handbook of Family Medicine (3rd ed). Cape Town: Oxford University Press, 2011.
  24. Mash B, Blitz J (Eds). South African Family Practice Manual (2nd ed). Cape Town: Van Schaik, 2006.

 

Prof Bob Mash This email address is being protected from spambots. You need JavaScript enabled to view it. on behalf of the SA Academy of Family Physicians, Education and Training Committee.

4th November 2014

2017 20141112 National Position Paper on Family Medicine. Copyright © SAAFP All Rights Reserved.
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