Prof Saloojee addressing Academy of Family Physicians congress delegates

The data
scarcity in South Africa’s current primary health care (PHC) environment is one
of the main reasons the progress of the national Re-engineering of Primary Health
Care Initiative launched in 2011 can only be described as “disappointing”.

“Too
little data, but a lot of opinion,” Prof Haroon Salojee, head of the division
of Community Paediatrics at the University of the Witwatersrand, lamented when
delivering the KM Seedat Memorial Lecture at the SA Academy of Physicians’
(SAAFP’s) 22nd National Family Practitioners Congress in Midrand at the weekend.

The
lecture is presented as a traditional SAAFOP Congress keynote address in memory
of the revered Dr KM Seedat, a medical doctor turned lawyer well-known for his struggle
period activities during which he became the first president of what is now the
National Association of Democratic Lawyers.

Adding
that there was “very little to inspire” in the development of primary care
services throughout the land, Saloojee indicated that a good part of the problem was limited extensions of services of care and support beyond that of HIV
and Aids.

Not
helping the situation was private doctors’ mistrust of the government, and
family practitioners’ discontent with their practice limitations.

A
component of the national initiative, the establishment of district-based clinical
specialist teams (DCSTs), Saloojee noted, had been particularly concerning in
that, by 2017,
 only eight
of 46 districts had full teams (excluding the anaesthetist): “A quarter of districts
did not have sufficient members with the knowledge or skills to cover expected
DCST work in any meaningful way,” he added.

“Concerns
regarding role clarity and role overlap persist, often mentioned in the context
of high DCST specialist members’ salaries.”

Individual
competence, both clinical and managerial, as well as work ethic among some members
was often questioned, while the DCSTs themselves refer to the lack of
operational support, high team vacancy rates, inappropriate tasking, and/or
demands, and a failure of the district to implement or respond to their
recommendations.

Equally disturbing,
said Saloojee, was that family physicians, trained as generalists, found it a
challenge to restrict their practice to MCH. This, he said, was aggravated by
the fact that DCSTs feel that the role of the family practitioner and
especially the private health care nurse within the team was not clear.

Other primary
health care challenges cited by Saloojee included private doctors mistrust of
government, contract formalities hampering the movement of doctors to assist in
other facilities, limiting work hours, as well as health system efficiencies at
large such as obtaining patient files, accessing results and the lack of
equipment and resources.

Key system
changes Salojee suggested to address some of the problems included “replacing
cadre deployment with meritocracy”, decentralising (devolution of) power to
districts, optimal capacity building, skills development in problem solving,
and mechanisms to hold providers accountable for access and quality and to ensure
citizens are given a voice.

“Based on
the current evidence on implementation at this ‘halfway mark’ of the
re-engineering primary health care intervention, “ the Wits professor
concluded, “a structured formal review of its successes and failures is
warranted and new directions need to be carved for the strategy.”