Published: 07/06/2021

31 May 2021

Dear Professor Laetitia Rispel,

NATIONAL DEPARTMENT OF HEALTH: 2030 HUMAN RESOURCES FOR HEALTH STRATEGY

This new policy on Human Resources for Health in South Africa has come to my attention as President of the South African Academy of Family Physicians. In this open letter the Academy as the professional body for Family Medicine in South Africa and official member of the World Organisation of Family Doctors would like to respond to and comment on the recommendations. You may have noticed a recent editorial on the policy document by Professor Klaus Von Pressentin, the Editor-in-Chief of the South African Family Practice Journal.1

Firstly, we appreciate the work that has gone into this report and the many constraints that your work streams faced in trying to put forward sensible recommendations. We also appreciate and agree with the vision and principles underlying the document. Particularly the commitment to universal health coverage.
Nevertheless, we believe that once again the policy fails to understand the contribution of Family Medicine to the health system. I say once again, because the previous Human Resources for Health policy in 2011 erroneously saw Family Medicine as a sub-specialty of Internal Medicine and thus made recommendations based on incorrect assumptions.2

We have previously submitted a position paper on Family Medicine to the National Department of Health at their request in an attempt to clarify the contribution of Family Medicine.3 Family physicians are specialists in Family Medicine and trained to work as expert generalists in primary health care and district hospitals. We see their role as key and leading members of health care teams in primary health care and district hospitals. The National Development Plan sees them as key drivers of quality and clinical governance in the district health services.
Your policy document makes use of three perspectives on health workforce needs and costs. In this letter I will tackle them in reverse order.

Model III looks at the needs for specialist doctors and was conducted by PRECEPT and commissioned by the Discovery Foundation. According to Table 8 this analysis looked only at tertiary and quaternary health services. Family physicians as medical specialists would be found in primary care facilities and district hospitals and only very rarely at these higher levels of the health system. It is disappointing, although maybe no surprise, given these assumptions, that the model concludes we need more anaesthetists, orthopaedic surgeons, paediatricians, physicians, psychiatrists and surgeons than family physicians. Clearly this model is unable to give sensible recommended targets for Family Medicine.

I struggle to think of any health systems that has concluded they need more tertiary hospital based specialists than family physicians, given that family physicians support the broad base of the district health system. This model recommends a target for 2025 of 2.14 family physicians per 100,000 population. One can compare this rate with countries such as Mexico (30 family physicians per 100,000) or Thailand (9 family physicians per 100,000) and the World Bank recommendation (30 family physicians per 100,000).1

Model II focuses on the workforce for primary health care and makes the assumption that family physicians only appear in this scenario in relationship to District Clinical Specialist Teams (DCST) (page 36). The DCSTs were of course introduced to target maternal and child health and to help us achieve the Millennium Development Goals. The concept was that a district level team of specialists would support clinical governance in the district and include a specialist family physician. This conceptualization of family physicians of course misses the point that they are being deployed mainly at district hospitals and primary care facilities within the district. Family physicians are not visiting from some regional level hospital and operating only at a district level. Table 10 should list family physicians as a separate and vital member of the primary health care team and not aggregate them together with all other specialists in the DCST. At a minimum every community health/day centre and sub-district should have a family physician.

Between Model II and Model III it also appears that the district hospital is not considered as a vital component of the health system. Model II only focuses on primary care and Modell III on tertiary and quaternary hospitals. District hospitals are of course a hugely important component of district health services and in rural areas are intrinsically linked with supporting primary health care. Family physicians have been seen as a key solution to the skills gap at district hospitals, particularly for surgical, anaesthetic and obstetric skills.4 Once again the omission of district hospitals in the policy document underestimates the number of family physicians needed for the country. Our previous position paper suggested a minimum short term goal of one family physician for every district hospital, but experience is also showing that most such hospitals need at least two family physicians.

Model I looks at the situation with regard to health equity, particularly between provinces. As with most other health care workers this is an issue also for the distribution of family physicians. We refer you to our recently published analysis of family physicians in the country.5

Overall, therefore, it is with a sense of exasperation that once again it appears as if the policymakers involved in this document have misunderstood the discipline of Family Medicine. My only hope is that it is not too late to rectify these misunderstandings before it is signed into policy.

Yours sincerely,

DISTINGUISHED PROFESSOR BOB MASH
PRESIDENT SA ACADEMY OF FAMILY PHYSICIANS AND STELLENBOSCH UNIVERSITY

PROFESSOR ANDREW ROSS
VICE-PRESIDENT SA ACADEMY OF FAMILY PHYSICIANS AND UNIVERSITY OF KWAZULU NATAL

PROFESSOR HANNEKE BRITS
DIRECTOR SA ACADEMY OF FAMILY PHYSICIANS AND UNIVERSITY OF FREE STATE

DR NONHLANHLA KHUMALO
DIRECTOR SA ACADEMY OF FAMILY PHYSICIANS AND UNIVERSITY OF WITWATERSRAND

DR TASLEEM RAS
DIRECTOR SA ACADEMY OF FAMILY PHYSICIANS AND UNIVERSITY OF CAPE TOWN

DR JENNY NASH
DIRECTOR SA ACADEMY OF FAMILY PHYSICIANS AND RURAL DOCTORS ASSOCIATION OF SA

Reference list
1. Von Pressentin KB. The new human resources for health policy supports the need for South African family medicine training programmes to triple their output. South African Fam Pract 2021; 63: 2.
2. Department of Health. Human Resources for Health, South Africa: HRH Strategy for the Health Sector. Pretoria: Department of Health, 2011.
3. Mash R, Ogunbanjo G, Naidoo SS, Hellenberg D. The contribution of family physicians to district health services: A national position paper for South Africa. South African Fam Pract 2015; 57: 54–61.
4. Chu K, Naidu P, Reid S, et al. The role of family physicians in emergency and essential surgical care in the district health system in South Africa. S Afr Fam Pract. 2020;62(1), a5117. https://doi.org/10.4102/safp.v62i1.5117
5. Tiwari R, Mash R, Karangwa I, Chikte U. A human resources for health analysis of registered family medicine specialists in South Africa: 2002–19. Fam Pract 2020; published online Sept 11. DOI:10.1093/fampra/cmaa084.