Shabir Moosa - Academia.edu (original) (raw)

Papers by Shabir Moosa

Research paper thumbnail of Security and skills: the two key issues in health worker migration

Global Health Action, Jul 28, 2014

Background: Migration of health workers from Africa continues to undermine the universal provisio... more Background: Migration of health workers from Africa continues to undermine the universal provision of quality health care. South Africa is an epicentre for migration Á it exports more health workers to highincome countries than any other African country and imports health workers from its lower-income neighbours to fill the gap. Although an intergovernmental agreement in 2003 reduced the very high numbers migrating from South Africa to the United Kingdom, migration continues to other high-income Englishspeaking countries and few workers seem to return although the financial incentive to work abroad has lessened. A deeper understanding of reasons for migration from South Africa and post-migration experiences is therefore needed to underpin policy which is developed in order to improve retention within source countries and encourage return. Methods: Semi-structured interviews were conducted with 16 South African doctors and nurses who had migrated to the United Kingdom. Interviews explored factors influencing the decision to migrate and postmigration experiences. Results: Salary, career progression, and poor working conditions were not major push factors for migration. Many health workers reported that they had previously overcome these issues within the South African healthcare system by migrating to the private sector. Overwhelmingly, the major push factors were insecurity, high levels of crime, and racial tension. Although the wish to work and train in what was perceived to be a first-class care system was a pull factor to migrate to the United Kingdom, many were disappointed by the experience. Instead of obtaining new skills, many (particularly nurses) felt they had become 'de-skilled'. Many also felt that working conditions and opportunities for them in the UK National Health Service (NHS) compared unfavourably with the private sector in South Africa. Conclusions: Migration from South Africa seems unlikely to diminish until the major concerns over security, crime, and racial tensions are resolved. However, good working conditions in the private sector in South Africa provide an occupational incentive to return if security did improve. Potential migrants should be made more aware of the risks of losing skills while working abroad that might prejudice return. In addition, re-skilling initiatives should be encouraged.

Research paper thumbnail of Why there is an inverse primary-care law in Africa

The Lancet Global Health, Dec 1, 2013

Research paper thumbnail of The views of key leaders in South Africa on implementation of family medicine: critical role in the district health system

BMC Family Practice, Jun 25, 2014

Background: Integrated team-based primary care is an international imperative. This is required m... more Background: Integrated team-based primary care is an international imperative. This is required more so in Africa, where fragmented verticalised care dominates. South Africa is trying to address this with health reforms, including Primary Health Care Re-engineering. Family physicians are already contributing to primary care despite family medicine being only fully registered as a full specialty in South Africa in 2008. However the views of leaders on family medicine and the role of family physicians is not clear, especially with recent health reforms. The aim of this study was to understand the views of key government and academic leaders in South Africa on family medicine, roles of family physicians and human resource issues. Methods: This was a qualitative study with academic and government leaders across South Africa. In-depth interviews were conducted with sixteen purposively selected leaders using an interview guide. Thematic content analysis was based on the framework method. Results: Whilst family physicians were seen as critical to the district health system there was ambivalence on their leadership role and 'specialist' status. National health reforms were creating both threats and opportunities for family medicine. Three key roles for family physicians emerged: supporting referrals; clinical governance/quality improvement; and providing support to community-oriented care. Respondents' urged family physicians to consolidate the development and training of family physicians, and shape human resource policy to include family physicians. Conclusions: Family physicians were seen as critical to the district health system in South Africa despite difficulties around their precise role. Whilst their role was dominated by filling gaps at district hospitals to reduce referrals it extended to clinical governance and developing community-oriented primary care-a tall order, requiring strong teamwork. Innovative team-based service delivery is possible despite human resource challenges, but requires family physicians to proactively develop team-based models of care, reform education and advocate for clearer policy, based on the views of these respondents.

Research paper thumbnail of Insights of private general practitioners in group practice on the introduction of National Health Insurance in South Africa

African Journal of Primary Health Care & Family Medicine, Jun 15, 2016

Background Healthcare in South Africa (SA) is fragmented and inequitable, with public health fund... more Background Healthcare in South Africa (SA) is fragmented and inequitable, with public health funds servicing 85% of the population, whilst a similar amount is spent privately by 15% of the population on voluntary prepaid medical insurance. Private costs are escalating, driven by hospitals and specialists. 1 Most generalist doctors are in private practice, mostly fee-for-service, and function only with undergraduate training. The public primary healthcare (PHC) system is 'nurse-driven' with doctors in a marginal role, ostensibly because of shortages of doctors and a GP bias against early post-apartheid public health reforms. 2,3 Full-time postgraduate training in family medicine only started in 2008 with family physicians focused on public service district hospitals. Key stakeholders in SA see family physicians as critical to the district health services (DHS), with a growing focus on team-based family practices and community-oriented primary care. 4 Private general practitioners (GPs) do provide some services to the public service, with sessions (where they work in clinics and are paid per hour), or offer free immunisation, family planning and HIV counselling and testing in their rooms with free materials provided by the public service, and an informal arrangement that only services are charged for and not materials. The South African government is planning a National Health Insurance (NHI) system from 2012 to 2025 to address the public-private inequity in spending and human resource and to harness private resources, including GPs. GPs are to be included in capitation contracts alongside current nurse-dominated public PHC services. 5 The views of GPs working in group practices are important as the NHI expects capitation contracts to be with accredited provider groups. 5 The uptake in capitation contracts depends on rates being acceptable to providers. 6 The major cost elements are staff, operations and investments. Currently, utilisation of the public DHS in SA is approximately two visits per person per year, although it is expected to be three under NHI, because of improved services. In NHI policy debate in SA, it has been raised that any random pool of 1000 people (as the smallest number) would share Background: The South African government intends to contract with 'accredited provider groups' for capitated primary care under National Health Insurance (NHI). South African solo general practitioners (GPs) are unhappy with group practice. There is no clarity on the views of GPs in group practice on contracting to the NHI. Objectives: To describe the demographic and practice profile of GPs in group practice in South Africa, and evaluate their views on NHI, compared to solo GPs. Methods: This was a descriptive survey. The population of 8721 private GPs in South Africa with emails available were emailed an online questionnaire. Descriptive statistical analyses and thematic content analysis were conducted. Results: In all, 819 GPs responded (568 solo GPs and 251 GPs in groups). The results are focused on group GPs. GPs in groups have a different demographic practice profile compared to solo GPs. GPs in groups expected R4.86 million ($0.41 million) for a hypothetical NHI proposal of comprehensive primary healthcare (excluding medicines and investigations) to a practice population of 10 000 people. GPs planned a clinical team of 8 to 12 (including nurses) and 4 to 6 administrative staff. GPs in group practices saw three major risks: patient, organisational and government, with three related risk management strategies. Conclusions: GPs can competitively contract with NHI, although there are concerns. NHI contracting should not be limited to groups. All GPs embraced strong teamwork, including using nurses more effectively. This aligns well with the emergence of family medicine in Africa.

Research paper thumbnail of Introducing a national health insurance system in South Africa: A general practitioner’s bottom-up approach to costing

South African Medical Journal, Aug 1, 2012

Research paper thumbnail of Perspectives on key principles of generalist medical practice in public service in sub-saharan africa: a qualitative study

BMC Family Practice, Jul 4, 2011

Background: The principles and practice of Family Medicine that arose in developed Western countr... more Background: The principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context. Methods: A descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed. Results: The respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patient's perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being lifelong learners themselves. However, their role in the community, was found to be more aspirational than real. Conclusions: The study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.

Research paper thumbnail of ‘You can't stay away from your family’: a qualitative study of the ongoing ties and future plans of South African health workers in the United Kingdom

Global Health Action, Mar 17, 2015

Background: Migration of African-trained health workers to countries with higher health care work... more Background: Migration of African-trained health workers to countries with higher health care worker densities adds to the severe shortage of health personnel in many African countries. Policy initiatives to reduce migration levels are informed by many studies exploring the reasons for the original decision to migrate. In contrast, there is little evidence to inform policies designed to facilitate health workers returning home or providing other forms of support to the health system of their home country. Objective: This study explores the links that South African-trained health workers who now live and work in the United Kingdom maintain with their country of training and what their future migration plans may be. Design: Semi-structured interviews were conducted with South African trained health workers who are now living in the United Kingdom. Data extracts from the interviews relating to current links with South Africa and future migration plans were studied. Results: All 16 participants reported strong ongoing ties with South Africa, particularly through active communication with family and friends, both face-to-face and remotely. Being South African was a significant part of their personal identity, and many made frequent visits to South Africa. These visits sometimes incorporated professional activities such as medical work, teaching, and charitable or business ventures in South Africa. The presence and location of family and spouse were of principal importance in helping South African-trained health care workers decide whether to return permanently to work in South Africa. Professional aspirations and sense of duty were also important motivators to both returning and to being involved in initiatives remotely from the United Kingdom. Conclusions: The main barrier to returning home was usually the development of stronger family ties in the United Kingdom than in South Africa. The issues that prompted the original migration decision, such as security and education, also remained important reasons to remain in the United Kingdom as long as they were perceived as unresolved at home. However, the strong residual feeling of identity and regular ongoing communication meant that most participants expressed a sense of duty to their home country, even if they were unlikely to return to live there full-time. This is a resource for training and short-term support that could be utilised to the benefit of African health care systems.

Research paper thumbnail of Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: a descriptive study with focus group discussions

Human Resources for Health, Jan 21, 2017

Background: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering i... more Background: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal. Methods: This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method. Results: There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team. Conclusions: Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues.

Research paper thumbnail of Educational ideas and lessons learnt : special series

South African Family Practice, Nov 1, 2005

Extracted from text ... SA Fam Pract 2005;47(10) 14 Article 3 Educational Ideas and Lessons Learn... more Extracted from text ... SA Fam Pract 2005;47(10) 14 Article 3 Educational Ideas and Lessons Learnt Morris G, MBChB(Pret), DTM&H(Wits) MPraxMed(MEDUNSA) Family Physician and Lecturer, Nelson Mandela Medical School Van Rooyen M, MBChB(Pret), MMed(FamMed)(Pret) Family Physician and Senior Lecturer, University of Pretoria Van Deventer C, MBChB(Stell), MFamMed(MEDUNSA) Principal Family Physician and Senior Lecturer, Unversity of Witwatersrand Conradie HH, MBChB(Stell), DCH(SA), MPraxMed(MEDUNSA) Senior Family Physician and Senior Lecturer, University of Stellenbosch Moosa SAH, MBChB(Natal), PHC Mgmt(Wits), MMed(FamMed)(MEDUNSA) Family Physician and Lecturer, University of Witwatersrand Smith S, MBChB(UOVS), MPraxMed(Pret) Family Physician and Senior Lecturer, University of Pretoria Derese A, MD, PhD Centre for Education Development, Department ..

Research paper thumbnail of Family medicine in Belgium - practical solutions for South Africa : special series

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The learning plan as a reflective tool for trainers of family medicine registrars : special series

South African Family Practice, Nov 1, 2005

Research paper thumbnail of Educational Ideas and Lessons Learnt

South African Family Practice, Nov 1, 2005

Research paper thumbnail of Evaluation Systems of Family Medicine Trainees in Belgium

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The Flemish model of training and supervision

South African Family Practice, Nov 1, 2005

Research paper thumbnail of Family Medicine Training: Ideas from Belgium

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The learning plan as a reflective tool for trainers of family medicine registrars

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The inverse primary care law in sub-Saharan Africa: a qualitative study of the views of migrant health workers

British Journal of General Practice, May 27, 2014

Background Many low-income and middle-income countries globally are now pursuing ambitious plans ... more Background Many low-income and middle-income countries globally are now pursuing ambitious plans for universal primary care, but are failing to deliver adequate care quality because of intractable human resource problems. Aim To understand why migrant nurses and doctors from sub-Saharan Africa did not wish to take up available posts in primary and first-contact care in their home countries. Design and setting Qualitative study of migrant health workers to Europe (UK, Belgium, and Austria) or southern Africa (Botswana and South Africa) from sub-Saharan Africa. Conclusions Clinicians are reluctant to work in the conditions they currently experience in primary care in sub-Saharan Africa and these conditions tend to get worse as poverty and need for primary care increases. This inverse primary care law undermines achievement of universal health coverage. Policy experience from countries outside Africa shows that it is not immutable.

Research paper thumbnail of Universal Health Coverage and Primary Healthcare: Lessons From Japan Comment on "Achieving Universal Health Coverage by Focusing on Primary Care in Japan: Lessons for Low- and Middle-Income Countries

International journal of health policy and management, Jan 28, 2016

A recent editorial by Naoki Ikegami has proposed three key lessons from Japan's experience of... more A recent editorial by Naoki Ikegami has proposed three key lessons from Japan's experience of achieving virtually universal coverage with primary healthcare services: the need to integrate the existing providers of primary healthcare services into the organised health system; the need to limit government commitments to finance hospital services and the need to empower providers of primary healthcare to influence decisions that influence their livelihoods. Although the context of low- and middle-income countries (LMICs) differs in many ways from Japan in the late 19th and early 20th centuries, the lesson that short-term initiatives to achieve universal coverage need to be complemented by an understanding of the factors influencing long-term change management remains highly relevant.

Research paper thumbnail of Use of digital health technologies in primary health care (PHC) in the Sub-Saharan Africa Region: a SWOT analysis (Preprint)

BACKGROUND In many health systems globally, digital health technologies (DHT) have become increas... more BACKGROUND In many health systems globally, digital health technologies (DHT) have become increasingly commonplace as a means of delivering primary care. COVID-19 has further increased the pace of this trend. While DHTs have been postulated to reduce inequalities, increase access, and strengthen health systems, how DHT implementation has been realised in the sub-Saharan Africa (SSA) healthcare environment remains to be further explored. OBJECTIVE To capture the multidisciplinary experiences of SSA experts and primary care healthcare providers using DHTs to explore the strengths and weaknesses, as well as opportunities and threats regarding the implementation and use of DHTs in SSA primary care settings. METHODS A combination of qualitative approaches was adopted (i.e., online focus groups and semi-structured interviews), using an online platform. Participants were recruited through AfroPHC and researchers contact networks, using convenience sampling, and included if having experienc...

Research paper thumbnail of Outcomes of a model integrating tuberculosis testing into COVID-19 services in South Africa

African Journal of Primary Health Care & Family Medicine

The coronavirus disease 2019 (COVID-19) pandemic led to a reordering of healthcare priorities. He... more The coronavirus disease 2019 (COVID-19) pandemic led to a reordering of healthcare priorities. Health resources were turned to the screening and diagnosis of COVID-19, leading to a reduction in tuberculosis (TB) testing and treatment initiation. An innovative model that integrated TB and COVID-19 services was adopted at primary care facilities in Johannesburg Health District, Gauteng. This short report illustrates results from this model’s implementation in two facilities. Patients were screened for COVID-19 at a single point of entry and separated according to screening result. Self-reported human immunodeficiency virus (HIV) status, symptom, and symptom duration were then used to determine TB risk amongst those screening positive for COVID-19. Data from clinical records were extracted. Approximately 9% of patients with a positive symptom screen (n = 76) were sent for a TB test and 84% were sent for a COVID-19 test. Amongst those sent for a TB test, 8% (n = 6) had TB detected, and ...

Research paper thumbnail of Security and skills: the two key issues in health worker migration

Global Health Action, Jul 28, 2014

Background: Migration of health workers from Africa continues to undermine the universal provisio... more Background: Migration of health workers from Africa continues to undermine the universal provision of quality health care. South Africa is an epicentre for migration Á it exports more health workers to highincome countries than any other African country and imports health workers from its lower-income neighbours to fill the gap. Although an intergovernmental agreement in 2003 reduced the very high numbers migrating from South Africa to the United Kingdom, migration continues to other high-income Englishspeaking countries and few workers seem to return although the financial incentive to work abroad has lessened. A deeper understanding of reasons for migration from South Africa and post-migration experiences is therefore needed to underpin policy which is developed in order to improve retention within source countries and encourage return. Methods: Semi-structured interviews were conducted with 16 South African doctors and nurses who had migrated to the United Kingdom. Interviews explored factors influencing the decision to migrate and postmigration experiences. Results: Salary, career progression, and poor working conditions were not major push factors for migration. Many health workers reported that they had previously overcome these issues within the South African healthcare system by migrating to the private sector. Overwhelmingly, the major push factors were insecurity, high levels of crime, and racial tension. Although the wish to work and train in what was perceived to be a first-class care system was a pull factor to migrate to the United Kingdom, many were disappointed by the experience. Instead of obtaining new skills, many (particularly nurses) felt they had become 'de-skilled'. Many also felt that working conditions and opportunities for them in the UK National Health Service (NHS) compared unfavourably with the private sector in South Africa. Conclusions: Migration from South Africa seems unlikely to diminish until the major concerns over security, crime, and racial tensions are resolved. However, good working conditions in the private sector in South Africa provide an occupational incentive to return if security did improve. Potential migrants should be made more aware of the risks of losing skills while working abroad that might prejudice return. In addition, re-skilling initiatives should be encouraged.

Research paper thumbnail of Why there is an inverse primary-care law in Africa

The Lancet Global Health, Dec 1, 2013

Research paper thumbnail of The views of key leaders in South Africa on implementation of family medicine: critical role in the district health system

BMC Family Practice, Jun 25, 2014

Background: Integrated team-based primary care is an international imperative. This is required m... more Background: Integrated team-based primary care is an international imperative. This is required more so in Africa, where fragmented verticalised care dominates. South Africa is trying to address this with health reforms, including Primary Health Care Re-engineering. Family physicians are already contributing to primary care despite family medicine being only fully registered as a full specialty in South Africa in 2008. However the views of leaders on family medicine and the role of family physicians is not clear, especially with recent health reforms. The aim of this study was to understand the views of key government and academic leaders in South Africa on family medicine, roles of family physicians and human resource issues. Methods: This was a qualitative study with academic and government leaders across South Africa. In-depth interviews were conducted with sixteen purposively selected leaders using an interview guide. Thematic content analysis was based on the framework method. Results: Whilst family physicians were seen as critical to the district health system there was ambivalence on their leadership role and 'specialist' status. National health reforms were creating both threats and opportunities for family medicine. Three key roles for family physicians emerged: supporting referrals; clinical governance/quality improvement; and providing support to community-oriented care. Respondents' urged family physicians to consolidate the development and training of family physicians, and shape human resource policy to include family physicians. Conclusions: Family physicians were seen as critical to the district health system in South Africa despite difficulties around their precise role. Whilst their role was dominated by filling gaps at district hospitals to reduce referrals it extended to clinical governance and developing community-oriented primary care-a tall order, requiring strong teamwork. Innovative team-based service delivery is possible despite human resource challenges, but requires family physicians to proactively develop team-based models of care, reform education and advocate for clearer policy, based on the views of these respondents.

Research paper thumbnail of Insights of private general practitioners in group practice on the introduction of National Health Insurance in South Africa

African Journal of Primary Health Care & Family Medicine, Jun 15, 2016

Background Healthcare in South Africa (SA) is fragmented and inequitable, with public health fund... more Background Healthcare in South Africa (SA) is fragmented and inequitable, with public health funds servicing 85% of the population, whilst a similar amount is spent privately by 15% of the population on voluntary prepaid medical insurance. Private costs are escalating, driven by hospitals and specialists. 1 Most generalist doctors are in private practice, mostly fee-for-service, and function only with undergraduate training. The public primary healthcare (PHC) system is 'nurse-driven' with doctors in a marginal role, ostensibly because of shortages of doctors and a GP bias against early post-apartheid public health reforms. 2,3 Full-time postgraduate training in family medicine only started in 2008 with family physicians focused on public service district hospitals. Key stakeholders in SA see family physicians as critical to the district health services (DHS), with a growing focus on team-based family practices and community-oriented primary care. 4 Private general practitioners (GPs) do provide some services to the public service, with sessions (where they work in clinics and are paid per hour), or offer free immunisation, family planning and HIV counselling and testing in their rooms with free materials provided by the public service, and an informal arrangement that only services are charged for and not materials. The South African government is planning a National Health Insurance (NHI) system from 2012 to 2025 to address the public-private inequity in spending and human resource and to harness private resources, including GPs. GPs are to be included in capitation contracts alongside current nurse-dominated public PHC services. 5 The views of GPs working in group practices are important as the NHI expects capitation contracts to be with accredited provider groups. 5 The uptake in capitation contracts depends on rates being acceptable to providers. 6 The major cost elements are staff, operations and investments. Currently, utilisation of the public DHS in SA is approximately two visits per person per year, although it is expected to be three under NHI, because of improved services. In NHI policy debate in SA, it has been raised that any random pool of 1000 people (as the smallest number) would share Background: The South African government intends to contract with 'accredited provider groups' for capitated primary care under National Health Insurance (NHI). South African solo general practitioners (GPs) are unhappy with group practice. There is no clarity on the views of GPs in group practice on contracting to the NHI. Objectives: To describe the demographic and practice profile of GPs in group practice in South Africa, and evaluate their views on NHI, compared to solo GPs. Methods: This was a descriptive survey. The population of 8721 private GPs in South Africa with emails available were emailed an online questionnaire. Descriptive statistical analyses and thematic content analysis were conducted. Results: In all, 819 GPs responded (568 solo GPs and 251 GPs in groups). The results are focused on group GPs. GPs in groups have a different demographic practice profile compared to solo GPs. GPs in groups expected R4.86 million ($0.41 million) for a hypothetical NHI proposal of comprehensive primary healthcare (excluding medicines and investigations) to a practice population of 10 000 people. GPs planned a clinical team of 8 to 12 (including nurses) and 4 to 6 administrative staff. GPs in group practices saw three major risks: patient, organisational and government, with three related risk management strategies. Conclusions: GPs can competitively contract with NHI, although there are concerns. NHI contracting should not be limited to groups. All GPs embraced strong teamwork, including using nurses more effectively. This aligns well with the emergence of family medicine in Africa.

Research paper thumbnail of Introducing a national health insurance system in South Africa: A general practitioner’s bottom-up approach to costing

South African Medical Journal, Aug 1, 2012

Research paper thumbnail of Perspectives on key principles of generalist medical practice in public service in sub-saharan africa: a qualitative study

BMC Family Practice, Jul 4, 2011

Background: The principles and practice of Family Medicine that arose in developed Western countr... more Background: The principles and practice of Family Medicine that arose in developed Western countries have been imported and adopted in African countries without adequate consideration of their relevance and appropriateness to the African context. In this study we attempted to elicit a priori principles of generalist medical practice from the experience of long-serving medical officers in a variety of African counties, through which we explored emergent principles of Family Medicine in our own context. Methods: A descriptive study design was utilized, using qualitative methods. 16 respondents who were clinically active medical practitioners, working as generalists in the public services or non-profit sector for at least 5 years, and who had had no previous formal training or involvement in academic Family Medicine, were purposively selected in 8 different countries in southern, western and east Africa, and interviewed. Results: The respondents highlighted a number of key issues with respect to the external environment within which they work, their collective roles, activities and behaviours, as well as the personal values and beliefs that motivate their behaviour. The context is characterized by resource constraints, high workload, traditional health beliefs, and the difficulty of referring patients to the next level of care. Generalist clinicians in sub-Saharan Africa need to be competent across a wide range of clinical disciplines and procedural skills at the level of the district hospital and clinic, in both chronic and emergency care. They need to understand the patient's perspective and context, empowering the patient and building an effective doctor-patient relationship. They are also managers, focused on coordinating and improving the quality of clinical care through teamwork, training and mentoring other health workers in the generalist setting, while being lifelong learners themselves. However, their role in the community, was found to be more aspirational than real. Conclusions: The study derived a set of principles for the practice of generalist doctors in sub-Saharan Africa based on the reported activities and approaches of the respondents. Patient-centred care using a biopsychosocial approach remains as a common core principle despite wide variations in context. Procedural and hospital care demands a higher level of skills particularly in rural areas, and a community orientation is desirable, but not widely practiced. The results have implications for the postgraduate training of family physicians in sub-Saharan Africa, and highlight questions regarding the realization of community-orientated primary care.

Research paper thumbnail of ‘You can't stay away from your family’: a qualitative study of the ongoing ties and future plans of South African health workers in the United Kingdom

Global Health Action, Mar 17, 2015

Background: Migration of African-trained health workers to countries with higher health care work... more Background: Migration of African-trained health workers to countries with higher health care worker densities adds to the severe shortage of health personnel in many African countries. Policy initiatives to reduce migration levels are informed by many studies exploring the reasons for the original decision to migrate. In contrast, there is little evidence to inform policies designed to facilitate health workers returning home or providing other forms of support to the health system of their home country. Objective: This study explores the links that South African-trained health workers who now live and work in the United Kingdom maintain with their country of training and what their future migration plans may be. Design: Semi-structured interviews were conducted with South African trained health workers who are now living in the United Kingdom. Data extracts from the interviews relating to current links with South Africa and future migration plans were studied. Results: All 16 participants reported strong ongoing ties with South Africa, particularly through active communication with family and friends, both face-to-face and remotely. Being South African was a significant part of their personal identity, and many made frequent visits to South Africa. These visits sometimes incorporated professional activities such as medical work, teaching, and charitable or business ventures in South Africa. The presence and location of family and spouse were of principal importance in helping South African-trained health care workers decide whether to return permanently to work in South Africa. Professional aspirations and sense of duty were also important motivators to both returning and to being involved in initiatives remotely from the United Kingdom. Conclusions: The main barrier to returning home was usually the development of stronger family ties in the United Kingdom than in South Africa. The issues that prompted the original migration decision, such as security and education, also remained important reasons to remain in the United Kingdom as long as they were perceived as unresolved at home. However, the strong residual feeling of identity and regular ongoing communication meant that most participants expressed a sense of duty to their home country, even if they were unlikely to return to live there full-time. This is a resource for training and short-term support that could be utilised to the benefit of African health care systems.

Research paper thumbnail of Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: a descriptive study with focus group discussions

Human Resources for Health, Jan 21, 2017

Background: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering i... more Background: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal. Methods: This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method. Results: There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team. Conclusions: Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues.

Research paper thumbnail of Educational ideas and lessons learnt : special series

South African Family Practice, Nov 1, 2005

Extracted from text ... SA Fam Pract 2005;47(10) 14 Article 3 Educational Ideas and Lessons Learn... more Extracted from text ... SA Fam Pract 2005;47(10) 14 Article 3 Educational Ideas and Lessons Learnt Morris G, MBChB(Pret), DTM&H(Wits) MPraxMed(MEDUNSA) Family Physician and Lecturer, Nelson Mandela Medical School Van Rooyen M, MBChB(Pret), MMed(FamMed)(Pret) Family Physician and Senior Lecturer, University of Pretoria Van Deventer C, MBChB(Stell), MFamMed(MEDUNSA) Principal Family Physician and Senior Lecturer, Unversity of Witwatersrand Conradie HH, MBChB(Stell), DCH(SA), MPraxMed(MEDUNSA) Senior Family Physician and Senior Lecturer, University of Stellenbosch Moosa SAH, MBChB(Natal), PHC Mgmt(Wits), MMed(FamMed)(MEDUNSA) Family Physician and Lecturer, University of Witwatersrand Smith S, MBChB(UOVS), MPraxMed(Pret) Family Physician and Senior Lecturer, University of Pretoria Derese A, MD, PhD Centre for Education Development, Department ..

Research paper thumbnail of Family medicine in Belgium - practical solutions for South Africa : special series

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The learning plan as a reflective tool for trainers of family medicine registrars : special series

South African Family Practice, Nov 1, 2005

Research paper thumbnail of Educational Ideas and Lessons Learnt

South African Family Practice, Nov 1, 2005

Research paper thumbnail of Evaluation Systems of Family Medicine Trainees in Belgium

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The Flemish model of training and supervision

South African Family Practice, Nov 1, 2005

Research paper thumbnail of Family Medicine Training: Ideas from Belgium

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The learning plan as a reflective tool for trainers of family medicine registrars

South African Family Practice, Nov 1, 2005

Research paper thumbnail of The inverse primary care law in sub-Saharan Africa: a qualitative study of the views of migrant health workers

British Journal of General Practice, May 27, 2014

Background Many low-income and middle-income countries globally are now pursuing ambitious plans ... more Background Many low-income and middle-income countries globally are now pursuing ambitious plans for universal primary care, but are failing to deliver adequate care quality because of intractable human resource problems. Aim To understand why migrant nurses and doctors from sub-Saharan Africa did not wish to take up available posts in primary and first-contact care in their home countries. Design and setting Qualitative study of migrant health workers to Europe (UK, Belgium, and Austria) or southern Africa (Botswana and South Africa) from sub-Saharan Africa. Conclusions Clinicians are reluctant to work in the conditions they currently experience in primary care in sub-Saharan Africa and these conditions tend to get worse as poverty and need for primary care increases. This inverse primary care law undermines achievement of universal health coverage. Policy experience from countries outside Africa shows that it is not immutable.

Research paper thumbnail of Universal Health Coverage and Primary Healthcare: Lessons From Japan Comment on "Achieving Universal Health Coverage by Focusing on Primary Care in Japan: Lessons for Low- and Middle-Income Countries

International journal of health policy and management, Jan 28, 2016

A recent editorial by Naoki Ikegami has proposed three key lessons from Japan's experience of... more A recent editorial by Naoki Ikegami has proposed three key lessons from Japan's experience of achieving virtually universal coverage with primary healthcare services: the need to integrate the existing providers of primary healthcare services into the organised health system; the need to limit government commitments to finance hospital services and the need to empower providers of primary healthcare to influence decisions that influence their livelihoods. Although the context of low- and middle-income countries (LMICs) differs in many ways from Japan in the late 19th and early 20th centuries, the lesson that short-term initiatives to achieve universal coverage need to be complemented by an understanding of the factors influencing long-term change management remains highly relevant.

Research paper thumbnail of Use of digital health technologies in primary health care (PHC) in the Sub-Saharan Africa Region: a SWOT analysis (Preprint)

BACKGROUND In many health systems globally, digital health technologies (DHT) have become increas... more BACKGROUND In many health systems globally, digital health technologies (DHT) have become increasingly commonplace as a means of delivering primary care. COVID-19 has further increased the pace of this trend. While DHTs have been postulated to reduce inequalities, increase access, and strengthen health systems, how DHT implementation has been realised in the sub-Saharan Africa (SSA) healthcare environment remains to be further explored. OBJECTIVE To capture the multidisciplinary experiences of SSA experts and primary care healthcare providers using DHTs to explore the strengths and weaknesses, as well as opportunities and threats regarding the implementation and use of DHTs in SSA primary care settings. METHODS A combination of qualitative approaches was adopted (i.e., online focus groups and semi-structured interviews), using an online platform. Participants were recruited through AfroPHC and researchers contact networks, using convenience sampling, and included if having experienc...

Research paper thumbnail of Outcomes of a model integrating tuberculosis testing into COVID-19 services in South Africa

African Journal of Primary Health Care & Family Medicine

The coronavirus disease 2019 (COVID-19) pandemic led to a reordering of healthcare priorities. He... more The coronavirus disease 2019 (COVID-19) pandemic led to a reordering of healthcare priorities. Health resources were turned to the screening and diagnosis of COVID-19, leading to a reduction in tuberculosis (TB) testing and treatment initiation. An innovative model that integrated TB and COVID-19 services was adopted at primary care facilities in Johannesburg Health District, Gauteng. This short report illustrates results from this model’s implementation in two facilities. Patients were screened for COVID-19 at a single point of entry and separated according to screening result. Self-reported human immunodeficiency virus (HIV) status, symptom, and symptom duration were then used to determine TB risk amongst those screening positive for COVID-19. Data from clinical records were extracted. Approximately 9% of patients with a positive symptom screen (n = 76) were sent for a TB test and 84% were sent for a COVID-19 test. Amongst those sent for a TB test, 8% (n = 6) had TB detected, and ...