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The author comments on the discussion paper "Thoughts on the state of Family Medicine in South Africa" presented at 16th National Family Practitioners Conference in Cape Town. He discusses the role of family physicians in the provision of quality private medical services, clinical governance and all teaching levels within the district health system (DHS). Particular focus is given to family medicine training programme to ensure high-standard care in state health services.

Introduction: In sub-Saharan Africa (SSA), the physicians' ratio is increasing. There are clear indications that many of them have opted to work at the first-line of healthcare delivery systems, i.e. providing primary care. This constitutes an important change in African healthcare systems where the first line has been under the responsibility of nurse-practitioners for decades. Previous reviews on primary care physicians (PCPs) in SSA focused on the specific case of family physicians in English-speaking countries. This scoping review provides a broader mapping of the PCPs' practices in SSA, beyond family physicians and including francophone Africa. For this study, we defined PCPs as medical doctors who work at the first-line of healthcare delivery and provide generalist healthcare. Methods: We searched five databases and identified additional sources through purposively selected websites, expert recommendations, and citation tracking. Two reviewers independently selected studies and extracted and coded the data. The findings were presented to a range of stakeholders. Findings: We included 81 papers, mostly related to the Republic of South Africa. Three categories of PCPs are proposed: family physicians, "médecins généralistes communautaires", and general practitioners. We analysed the functioning of each along four dimensions that emerged from the data analysis: professional identity, governance, roles and activities, and output/outcome. Our analysis highlighted several challenges about the PCPs' governance that could threaten their effective contribution to primary care. More research is needed to investigate better the precise nature and performance of the PCPs' activities. Evidence is particularly needed for PCPs classified in the category of GPs and, more generally, PCPs in African countries other than the Republic of South Africa. Conclusions: This review sheds more light on the institutional, organisational and operational realities of PCPs in SSA. It also highlighted persisting gaps that remain in our understanding of the functioning and the potential of African PCPs. [ABSTRACT FROM AUTHOR]

Background: Health policy-makers in Africa are looking for local solutions to strengthen primary care teams. A South African national position paper (2015) described six aspirational roles of family physicians (FPs) working within the district health system. However, the actual contributions of FPs are unclear at present, and evidence is required as to how this cadre may be able to strengthen health systems. Methods: Using semi-structured interviews, this study sought to obtain the views of South African district health managers regarding the impact made by FPs within their districts on health system performance, clinical processes and health outcomes. Results: A number of benefits of FPs to the health system in South Africa were confirmed, including: their ability to enhance the functionality of the local health system by increasing access to a more comprehensive and coordinated health service, and by improving clinical services delivered through clinical care, capacitating the local health team and facilitating clinical governance activities. Conclusions: District managers confirmed the importance of all six roles of the FP and expressed both direct and indirect ways in which FPs contribute to strengthening health systems’ performance and clinical outcomes. FPs were seen as important clinical leaders within the district healthcare team. Managers recognised the need to support newly appointed FPs to clarify their roles within the healthcare team and to mature across all their roles. This study supports the employment of FPs at scale within the South African district health system according to the national position paper on family medicine. [ABSTRACT FROM PUBLISHER]

Background: The general practitioner contracting initiative (GPCI) is a health systems strengthening initiative piloted in the first phase of national health insurance (NHI) implementation in South Africa as it progresses towards universal health coverage (UHC). GPCI aimed to address the shortage of doctors in the public sector by contracting-in private sector general practitioners (GPs) to render services in public primary health care clinics. This paper explores the early inception and emergence of the GPCI. It describes three models of contracting-in that emerged and interrogates key factors influencing their evolution., Methods: This qualitative multi-case study draws on three cases. Data collection comprised document review, key informant interviews and focus group discussions with national, provincial and district managers as well as GPs (n = 68). Walt and Gilson's health policy analysis triangle and Liu's conceptual framework on contracting-out were used to explore the policy content, process, actors and contractual arrangements involved., Results: Three models of contracting-in emerged, based on the type of purchaser: a centralized-purchaser model, a decentralized-purchaser model and a contracted-purchaser model. These models are funded from a single central source but have varying levels of involvement of national, provincial and district managers. Funds are channelled from purchaser to provider in slightly different ways. Contract formality differed slightly by model and was found to be influenced by context and type of purchaser. Conceptualization of the GPCI was primarily a nationally-driven process in a context of high-level political will to address inequity through NHI implementation. Emergence of the models was influenced by three main factors, flexibility in the piloting process, managerial capacity and financial management capacity., Conclusion: The GPCI models were iterations of the centralized-purchaser model. Emergence of the other models was strongly influenced by purchaser capacity to manage contracts, payments and recruitment processes. Findings from the decentralized-purchaser model show importance of local context, provincial capacity and experience on influencing evolution of the models. Whilst contract characteristics need to be well defined, allowing for adaptability to the local context and capacity is critical. Purchaser capacity, existing systems and institutional knowledge and experience in contracting and financial management should be considered before adopting a decentralized implementation approach.

Background: Completion of a research assignment is a requirement for specialist training in South Africa. Difficulty with completion delays graduation and the supply of family physicians. The aim of this study was to explore the experience of registrars with their research in postgraduate family medicine training programmes. Methods: An explorative descriptive qualitative study. Extreme case purposive sampling selected registrars who had and had not completed their research on time, from all nine training programmes. Saturation was achieved after 12 semi-structured interviews. The framework method was used for data analysis, assisted by ATLAS.ti software. Results: The assumption of prior learning by teachers and supervisors contributed to a sense of being overwhelmed and stressed. Teaching modules should be more standardised and focussed on the practical tasks and skills, rather than didactic theory. Lengthy provincial and ethics processes, and lack of institutional support, such as scholarly services and financial support, caused delays. The expertise of the supervisor was important, and the registrar-supervisor relationship should be constructive, collaborative and responsive. The individual research experience was dependent on choosing a feasible project and having dedicated time. The balancing of personal, professional and academic responsibilities was challenging. Conclusion: Training programmes should revise the teaching of research and improve institutional processes. Supervisors need to become more responsive, with adequate expertise. Provincial support is needed for streamlined approval and dedicated research time. Contribution: The study highlights ways in which teaching, and completion of research can be improved, to increase the supply of family physicians to the country. [ABSTRACT FROM AUTHOR]

Background: Universal health coverage (UHC) improves national health outcomes while addressing social inequalities in access to quality healthcare services. The district health system (DHS) is critical to the success of UHC in South Africa through the National Health Insurance (NHI) scheme. Family physicians (FPs), as champions of primary care, are central to the DHS operation and implementation of NHI. Methods: This was a qualitative exploratory study that used semi-structured interviews to explore FPs views and engagement on NHI policy and implementation in their districts. Ten FPs were included through purposive sampling. Results: Most of the FPs interviewed were not engaged in either policy formulation or strategic planning. The NHI bill was seen as a theoretical ideology that lacked any clear plan. Family physicians expressed several concerns around corruption in governmental structures that could play out in NHI implementation. Family physicians felt unsupported within their district structures and disempowered to engage in rollout strategies. The FPs were able to provide useful solutions to health system challenges because of the design of their training programmes, as well as their experience at the primary care level. Conclusion: Healthcare governance in South Africa remains located in national and provincial structures. Devolution of governance to the DHS is required if NHI implementation is to succeed. The FPs need to be engaged in NHI strategies, to translate plans into actionable objectives at the primary care level. Contribution: This study highlights the need to involve FPs as key actors in implementing NHI strategies at a decentralised DHS governance level. [ABSTRACT FROM AUTHOR]

Globally, communication plays an integral role in public health strategies, from infectious diseases to diseases related to lifestyles. The evolution of the field of social and behaviour change communication (SBCC), combined with the need for evidence based practice and multi-level interventions to promote health, and human resource gaps in sub-Saharan Africa have led to the imperative to standardise and formalise the field. Moreover, current practitioners come from different disciplinary backgrounds underlining the need to define common core skills and competencies. This paper describes the partnership between the Wits School of Public Health and the Soul City Institute for Health and Development Communication and how the partners responded to this need. It highlights the factors influencing sustainable institutional capacity to provide quality assured, accredited training. We describe an unexpected positive response from a number of practitioner organisations that have chosen to send multiple staff members for training, specifically to build a critical mass within their organisations. Finally, we note the interest from (mostly) southern-based academic institutions in setting up similar programmes and postulate that south-south collaborations can contribute to building sustainable context specific and evidence-informed SBCC programmes in the global south.

Objectives: This study aimed to investigate the views of students involved in rural community-based medical attachments during their final year at medical school. The programme has been in existence for some time, but no formal evaluation thereof has yet taken place. This paper describes the first two phases of what is described as a quality improvement project: namely to describe the problem state and to discuss possible activities to improve the programme. Design, setting and subjects: The study adopted a mixture of quantitative and qualitative type research. Data were collected by means of a self-administered questionnaire which students at Nelson R Mandela Medical School, University of KwaZulu-Natal, completed at the end of their Family Medicine rotation. Consent was obtained from the participants and ethical approval granted by the University of KwaZulu-Natal Humanities and Social Science Ethics Committee. Results: Students were generally positive about their rural attachment experience. The majority (86%) believed that their skills adequately prepared them to enter the community. Allocation of a supervisor and rostering were found to be of great importance. Academic activities provided adequate learning opportunities. The majority (76%) of students who used hospital accommodation found it to be satisfactory, although it was an area that needed attention. Technological support was lacking. Fewer than 50% of students had access to such facilities. Conclusion: Students' responses were generally positive about the rural attachment experience, but logistical and technological support issues, as well as that of accommodation, need to be addressed if the programme is to flourish. Community-based education in a rural district hospital can provide unique learning opportunities for students if the opportunities are identified and the programme is well managed. [ABSTRACT FROM AUTHOR]

Glaucoma is a sight-threatening condition. A general practitioner (GP) should be able to diagnose glaucoma, know about the different management options, and refer appropriately. The aim of this paper is to provide a background to glaucoma, and describe the assessment and management of glaucoma patients. The role of the GP in the management of glaucoma and in creating awareness of glaucoma is put into perspective. [ABSTRACT FROM AUTHOR]

Background: Evidence from first world contexts support the notion that strong primary health care teams contain family physicians (FPs). African leaders are looking for evidence from their own context. The roles and scope of practice of FPs are also contextually defined. The South African family medicine discipline has agreed on six roles. These roles were incorporated into a family physician impact assessment tool, previously validated in the Western Cape Province. Methods: A cross-sectional study design was used to assess the perceived impact of family physicians across seven South African provinces. All FPs working in the district health system (DHS) of these seven provinces were invited to participate. Sixteen respondents (including the FP) per enrolled FP were asked to complete the validated 360-degree assessment tool. Results: A total number of 52 FPs enrolled for the survey (a response rate of 56.5%) with a total number of 542 respondents. The mean number of respondents per FP was 10.4 (SD = 3.9). The perceived impact made by FPs was high for five of the six roles. Co-workers rated their FP’s impact across all six roles as higher, compared to the other doctors at the same facility. The perceived beneficial impact was experienced equally across the whole study setting, with no significant differences when comparing location (rural vs. metropolitan), facility type or training model (graduation before and ≥ 2011). Conclusions: The findings support the need to increase the deployment of family physicians in the DHS and to increase the number being trained as per the national position paper. [ABSTRACT FROM AUTHOR]

Background: The health workforce is critical to strengthening district health services (DHS). In the public sector of South Africa, medical officers (MOs) are essential to delivering services in primary health care (PHC) and district hospitals. Family physicians, responsible for clinical governance, identified their retention as a key issue. Aim: To evaluate factors that influence retention of MOs in public sector DHS. Design & setting: A descriptive survey of MOs working in DHS, Western Cape, South Africa. Method: All 125 MOs working in facilities associated with the Stellenbosch University Family Physician Research Network (SUFPREN) were included in the survey. A questionnaire measured the prevalence of key factors that might be associated with retention (staying >4 years) and included the Satisfaction of Employees in Health Care (SEHC) tool and Short Warwick--Edinburgh Mental Wellbeing Scale (SWEMWBS). Data were collected in Research Electronic Data Capture (REDCap) and analysed in the Statistical Package for Social Sciences (SPSS). Results: Ninety-five MOs completed the survey. The overall rating of the facility (P = 0.001), age (P = 0.004), seniority (P = 0.015), career plans (P<0.001), and intention to stay in the public sector (P<0.001) were associated with retention. More personal factors such as social support (P = 0.007), educational opportunities for children (P = 0.002), and staying with one's partner (P = 0.036) were also associated with retention. Sex, rural versus urban location, district hospital versus primary care facility, overtime, remuneration, and additional rural allowance were not associated with retention. Conclusion: The overall rating of the facility was important and subsequent qualitative work has explored the underlying issues. These findings can guide strategies in the Western Cape and similar settings to retain MOs in the DHS. [ABSTRACT FROM AUTHOR]

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020–March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35–44 years (OR: 3.38; 95%CI: 1.15–9.88), >55 years (OR: 4.75; 95% CI 1.08–21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08–4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets. [ABSTRACT FROM AUTHOR]

The international #1WordforFamilyMedicine initiative serves to explore the identity of family physicians and allows the international Family Medicine community to collaborate on advocating the discipline. South African family physicians provided 42 responses via a social media and online survey. Two “word cloud” images were created based on two icons recognised as being truly South African around the world - the national flag and former president Nelson Mandela. The #1WorldforFamilyMedicine initiative was promoted by the World Organization of Family Doctors across the globe to help celebrate World Family Doctor Day on 19 May 2015. To date, over 70 images have been created in 50 different countries on six continents. The images represent family physicians' love for their profession and the community they serve. It is hoped that this initiative will help to inspire current and future Family Medicine and primary care providers. [ABSTRACT FROM AUTHOR]

Background: Coordinating care for patients is a key characteristic of effective primary care. Family physicians in the Western Cape formed a research network to enable them to perform practical research on key questions from clinical practice. The initial question selected by the network focused on evaluating the quality of referrals to and feedback from outpatient departments at referral hospitals to primary care providers in the Western Cape. Methods: A descriptive survey combined quantitative data collected from the medical records with quantitative and qualitative data collected from the patients by questionnaire. Family physicians collected data on consecutive patients who had attended outpatient appointments in the last three months. Data were analysed using the Statistical Package for the Social Sciences. Results: Seven family physicians submitted data on 141 patients (41% male, 59% female; 46% metropolitan, 54% rural). Referrals were to district (18%), regional (28%) and tertiary hospitals (51%). Referral letters were predominantly biomedical. Written feedback was available in 39% of patients. In 32% of patients, doctors spent time obtaining feedback; the patient was the main source of information in 53% of cases, although many patients did not know what the hospital doctor thought was wrong (36%). The quality of referrals differed significantly by district and type of practitioner, while feedback differed significantly by level of hospital. Conclusion: Primary care providers did not obtain reliable feedback on specialist consultations at referral hospital outpatients. Attention must be given to barriers to care as well as communication, coordination and relationships across the primary–secondary interface. [ABSTRACT FROM AUTHOR]

Background: The success of medical specialist-led antimicrobial stewardship activities in urban tertiary health care settings has been well documented. The issue of antimicrobial resistance remains an ongoing concern. This has particular relevance in primary health care communities treated from sub-district health services, which are organised around level-one district hospitals. District hospitals are typically staffed by generalist clinicians or medical officers with minimal access to the medical specialist physicians and pathologists who are available in the urban academic centres. Coordinated team-based activities aimed at implementing the South African Antibiotic Stewardship Programme (SAASP) principles of antimicrobial use are necessary. Methods: This open forum article describes the process of growing an institutional culture around antimicrobial stewardship from the perspective of a 90-bed district hospital and a regional referral hospital located in the rural Garden Route District of the Western Cape province. Results: A team of generalist health workers, inclusive of a family physician and medical officers, pharmacists and nursing colleagues, conducted weekly antimicrobial stewardship ward rounds. A clinical pathologist from the National Health Laboratory Service (NHLS), based at George Regional Hospital, consulted on these ward rounds monthly and provided guidance and advice to medical staff via telephone, email and WhatsApp. Undergraduate medical students and registrars in family medicine also attended these ward rounds and learnt from resulting discussions. This strengthened quality of care for patients and provided a platform for shared ongoing learning. Conclusion: This model can be applied to similar settings within South Africa, and further afield. [ABSTRACT FROM AUTHOR]

Purpose: Evidence of the influence of family physicians on health care is required to assist managers and policy makers with human resource planning in Africa. The international argument for family physicians derives mainly from research in high-income countries, so this study aimed to evaluate the influence of family physicians on the South African district health system.Methods: We conducted a cross-sectional observational study in 7 South African provinces, comparing 15 district hospitals and 15 community health centers (primary care facilities) with family physicians and the same numbers without family physicians. Facilities with and without family physicians were matched on factors such as province, setting, and size.Results: Among district hospitals, those with family physicians generally scored better on indicators of health system performance and clinical processes, and they had significantly fewer modifiable factors associated with pediatric mortality (mean, 2.2 vs 4.7, P =.049). In contrast, among community health centers, those with family physicians generally scored more poorly on indicators of health system performance and clinical processes, with significantly poorer mean scores for continuity of care (2.79 vs 3.03; P =.03) and coordination of care (3.05 vs 3.51; P =.02).Conclusions: In this study, having family physicians on staff was associated with better indicators of performance and processes in district hospitals but not in community health centers. The latter was surprising and is inconsistent with the global literature, suggesting that further research is needed on the influence of family physicians at the primary care level. [ABSTRACT FROM AUTHOR]

Primary health care is seen as the 'linchpin of effective health care delivery' by the Western Cape Government Health services and improving the quality of primary care, through clinical governance, is a key aspect of realising this vision. This article aims to provide an outline of the provincial clinical governance framework and to reflect on the experience and lessons learnt within the semi-rural Cape Winelands District in implementing this framework. Strategies that were used included the establishment of district clinical governance meetings; leadership development of both managers and family physicians, defining clinical governance activities and using routine monitoring and evaluation meetings as part of quality improvement cycles; developing clinicians competent to address the burden of disease; and focusing on establishing a primary health care approach in the district. Lessons learnt included that activities should take place within a supportive organisational culture with a focus on continuous quality improvement at all levels of the health system. A systematic approach to planning clinical governance at the district level should be balanced with a localised approach to encourage reflection, engagement and change. Recommendations for further implementation of clinical governance in the district are listed. [ABSTRACT FROM AUTHOR]

Strengthening primary health care is a national priority in South Africa, in order to improve quality of care and health outcomes, reduce inequity and to pave the way for National Health Insurance. The World Health Organization and World Health Assembly both recommend the inclusion of a primary care doctor with postgraduate training in Family Medicine in the primary healthcare team. Currently, medical practitioners without postgraduate training, and those who may need re-orientating and upskilling for the future re-engineered primary care system, are the largest pool of doctors in South Africa. Most of these doctors are of an age and at a stage in their careers where it is unlikely that they will train to be a family physician. This article reports on a national process to design a Postgraduate Diploma in Family Medicine which will meet the learning needs of primary care doctors in both the public and private sectors as they prepare for the future. A year-long process included two national stakeholder workshops, a survey of learning needs and two additional expert workshops before consensus could be reached on the design of the new diploma programme. The future roles and competencies required of primary care doctors, learning outcomes congruent with these roles, and an educational design, which could be delivered at scale commensurate with the national need by all of the relevant higher education institutions, were envisaged during this process. The design of this diploma, presented here, will now be developed into a revised or new programme by the higher education institutions, and implemented from 2016 onwards. [ABSTRACT FROM AUTHOR]

Background: The global epidemic of non-communicable disease (NCDs) has been linked with four modifiable risky lifestyle behaviours, namely smoking, unhealthy diet, physical inactivity and alcohol abuse. Primary care providers (PCPs) can play an important role in changing patient's risky behaviours. It is recommended that PCPs provide individual brief behaviour change counselling (BBCC) as part of everyday primary care. This study is part of a larger project that re-designed the current training for PCPs in South Africa, to offer a standardized approach to BBCC based on the 5 As and a guiding style. This article reports on a qualitative sub-study, which explored whether the training intervention changed PCPs perception of their confidence in their ability to offer BBCC, whether they believed that the new approach could overcome the barriers to implementation in clinical practice and be sustained, and their recommendations on future training and integration of BBCC into curricula and clinical practice. Methods: This was a qualitative study that used verbal feedback from participants at the beginning and end of the training course, and twelve individual in-depth interviews with participants once they had returned to their clinical practice. Results: Although PCP's confidence in their ability to counselling improved, and some thought that time constraints could be overcome, they still reported that understaffing, lack of support from within the facility and poor continuity of care were barriers to counselling. However, the current organisational culture was not congruent with the patient-centred guiding style of BBCC. Training should be incorporated into undergraduate curricula of PCPs for both nurses and doctors, to ensure that counselling skills are embedded from the start. Existing PCPs should be offered training as part of continued professional development programmes. Conclusions: This study showed that although training changed PCPs perception of their ability to offer BBCC, and increased their confidence to overcome certain barriers to implementation, significant barriers remained. It is clear that to incorporate BBCC into everyday care, not only training, but also a whole systems approach is needed, that involves the patient, provider, and service organisation at different levels. [ABSTRACT FROM AUTHOR]

To address problems of inadequate public health services, escalating private healthcare costs and widening health inequalities, the South Africa (SA) Government has launched a bold new proposal to introduce a universal, comprehensive and integrated system for all SAs; National Health Insurance. Though attention has been devoted to the economics of universal coverage less attention has been paid to other potential challenges, in particular the important role played by the clinicians tasked with implementing the reforms. However, historical and comparative analysis reveals that whenever health systems undergo radical reform, the medical profession is instrumental in determining its nature and outcomes. Moreover, early indications suggest many SA private general practitioners (GPs) are opposed to the measures-and it is not yet known whether they will comply with the proposals. This study therefore analyses the dynamics and potential success of the reforms by directly examining the perceptions of the SA medical profession, in particular private-sector GPs. It draws on a conceptual framework which argues that understanding human motivation and behaviour is essential for the successful design of social policy. Seventy-six interviews were conducted with clinicians in the Eastern Cape Province in 2012. The findings suggest that the SA government will face significant challenges in garnering the support of private GPs. Concerns revolved around remuneration, state control, increased workload, clinical autonomy and diminished quality of care and working conditions. Although there were as yet few signs of mobilization or agency by private clinicians in the policy process, the findings suggests that it will be important for the government to directly address their concerns in order to ensure a stable transition and successful implementation of the reforms. [ABSTRACT FROM AUTHOR]

Background: Strengthening primary health care in South Africa is a prerequisite for the successful introduction of National Health Insurance. Primary care doctors from both the public and private sectors are an essential contributor to achieving this goal. In order to prepare these doctors for their future role, a national diploma training programme is being developed. This study aimed to evaluate the learning needs of primary care doctors and to assist with the design of the diploma. Methods: A descriptive survey of 170 primary care doctors (80 medical officers and 90 private practitioners), from eight provinces in South Africa, in terms of their use of 30 key guidelines, performance of 85 clinical skills and confidence in 12 different roles. Results: Doctors had read the majority of the guidelines (20/30), but few had been implemented in practice (6/30). All of the doctors had been trained in the clinical skills; however, none had taught these skills to others in the last year. Primary care doctors reported having performed the majority of the skills within the last year (70/85). Doctors had performed 7/12 roles in the last year, while 5/12 had not been engaged with. The weakest roles were those of change agent and community advocate, while the strongest roles were competent clinician, capability builder and collaborator. There were a number of significant differences (p < 0.05) between the learning needs of medical officers and private practitioners. Conclusion: These findings will help guide the development of a new Diploma in Family Medicine programme for South Africa. [ABSTRACT FROM AUTHOR]

Background Policy makers in Africa are ambivalent about the need for family physicians to strengthen district health services. Evidence on the impact of family physicians is therefore needed. The aim was to develop a tool to evaluate the impact of family physicians on district health services according to the six expected roles that have been defined nationally. Methods Mixed methods were used to develop, validate, pilot and test the reliability of the tool in the Western Cape Province, South Africa. An expert panel validated the content and construction of the tool. The tool was piloted by 94 respondents who evaluated eight family physicians. Cronbach alpha scores were calculated to test the reliability of the tool. The impact of these family physicians in the pilot study was also analysed. Results A draft tool was successfully developed, validated, and proved reliable (Cronbach alpha >0.8). The overall scores (scale of 1-4) were: Care provider = 3.5, Consultant = 3.4, Leader and champion of clinical governance = 3.4, Capacity builder = 3.3, Clinical trainer and supervisor = 3.2 and Champion of community-orientated primary care (COPC) = 3.1. The impact on COPC was significantly less than the impact of other roles (p < 0.05). Conclusion The Family Physician Impact Evaluation Tool can be used to measure the impact of family physicians in South Africa. The pilot study shows that the family physicians are having most impact in terms of clinical care and clinical governance, and a lesser impact in terms of clinical training, capacity-building and especially COPC. [ABSTRACT FROM AUTHOR]

Background: Since 2007 a portfolio of learning has become a requirement for assessment of postgraduate family medicine training by the Colleges of Medicine of South Africa. A uniform portfolio of learning has been developed and content validity established among the eight postgraduate programmes. The aim of this study was to investigate the portfolio's acceptability, educational impact, and perceived usefulness for assessment of competence. Methods: Two structured questionnaires of 35 closed and open-ended questions were delivered to 53 family physician supervisors and 48 registrars who had used the portfolio. Categorical and nominal/ordinal data were analysed using simple descriptive statistics. The open-ended questions were analysed with ATLAS.ti software. Results: Half of registrars did not find the portfolio clear, practical or feasible. Workshops on portfolio use, learning, and supervision were supported, and brief dedicated time daily for reflection and writing. Most supervisors felt the portfolio reflected an accurate picture of learning, but just over half of registrars agreed. While the portfolio helped with reflection on learning, participants were less convinced about how it helped them plan further learning. Supervisors graded most rotations, suggesting understanding the summative aspect, while only 61% of registrars reflected on rotations, suggesting the formative aspects are not yet optimally utilised. Poor feedback, the need for protected academic time, and pressure of service delivery impacting negatively on learning. Conclusion: This first introduction of a national portfolio for postgraduate training in family medicine in South Africa faces challenges similar to those in other countries. Acceptability of the portfolio relates to a clear purpose and guide, flexible format with tools available in the workplace, and appreciating the changing educational environment from university-based to national assessments. The role of the supervisor in direct observations of the registrar and dedicated educational meetings, giving feedback and support, cannot be overemphasized. [ABSTRACT FROM AUTHOR]

Looks into the increasing number of South African medical school graduates recruited in Canada. Concerns about the brain drain; Job offers from Canada, United Kingdom, New Zealand and Australia in the South African Medical Journal (SAMJ); Statistics on the number of South Africans practising in various countries; Political and financial problems in South Africa; Crimes; Efforts by South Africa to discourage the poaching of physicians by wealthy countries.