The future of general practice in South Africa.

There is a shortage of human resources in Africa but also poor management by governments with poor working environments and career paths in primary care1 and maldistribution of healthcare professionals. Post-apartheid South Africa saw black nurses moved out of hospitals dominated by white doctors to ‘nurse-driven’ district health services, citing ‘doctor shortage’. The government has struggled to regulate the private sector that exploded as public hospitals deteriorated and specialists moved in droves to private hospitals. Total healthcare expenditure for South Africa in 2012–2013 was R122 billion for public services for 42 million people, with a private sector spend of R103 billion on only 8.7 million people. The African National Congress has been championing national health insurance (NHI) since 2008, including GPs as providers. Government has included primary healthcare (PHC) re-engineering in NHI policy since 2011, fashioned around three streams: district specialist teams, school health teams and PHC outreach teams, consisting of two professional nurses, one enrolled nurse, and six community health workers, providing all PHC services, including treatment for ‘minor illness’, to a defined population of 7660 people.2 Interim evaluation suggests that this model is struggling with accountability and skills. The role of the GP has been declining in both private and public sectors. Doctors are not attracted to public sector primary care in clinics where they are meaninglessly ‘pushing numbers’ as employees and subordinate to nurse managers.3 Patients bypass clinics to get to doctors in hospitals or visit private GPs. GPs, as doctors just finishing their medical school and setting up shop with no postgraduate training, occupy a threatened space with ageing (mean age 46 years) and declining competencies. GPs are willing to engage with government capitation at the same cost as the public services PHC.4 This could be linked to postgraduate training in family medicine and will move many more clinicians into primary care. Government has ample resources, including grants from the European Union and UK, but is reluctant to contract fully with GPs, even in pilots, with the Minister of Health responding, ‘How will we monitor them?’. Instead the minister wants to contract doctors to work in public clinics for a few hours a week. Lessons from the UK, to include and incentivise GPs as complete service providers, appear lost. There is a strong need for better primary care in South Africa. Resources are not the real problem, but political will and trust are.