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The importance of integrated PHC teamwork to UHC in SA: Joburg case

29th April 2013

Public SeminarGhent

Dr Shabir Moosa

Family Physician, Wits-Jhb Dept of Family Medicine

Contents

• Africa in 50 years• Experience in Joburg PHC• COPC Project & Difficulties• Exploring NHI & GP-led care• Comments/Questions

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Africa in 50 years

• WHO docs• African Development Bank (2010)

– Africa in 50 years– Growth exceeding world growth but not Asia– Projections - 2010� 2060

• 74% working age• 40% � 65% urban dwellers• 34%� 42% middle class• 7%�99% broadband penetration• 127�45/1000 child mortality• 2.2%�1.3% HIV prevalence in total population• Growing share of world population 2.7b >India/China• Growing middle class 1.1b > India/China

Africa in 50 years

• African Development Bank (2010)– Drivers of change

• Global drivers of change (structure of global markets)• New technologies (genomics/pharm/biotech)• Changing rules of game (global trade/agreements)• Physical drivers• Human drivers• Private sector

– Consequences• Urbanisation will accelerate• Migration will increase > in Africa• Agriculture is likely to decline• Natural resources remain important

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Africa in 50 years

• African Development Bank (2010)– Policy choices

• Country level– Invest in cities– Manage migration

• Collective responses– Regional integration– Boosting market access

• Private sector/democratisation

Experiences Joburg PHC

• FM established in Gauteng 2006 • Stakeholder views in primary care on:

– Clinical priorities, – Role of doctors – Role of Family Medicine

• Qualitative study x 9 FGDs 2007-2008– doctors, interns, nurse-clinicians, clinic

managers and senior managers

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Experiences Joburg PHC

• Clinical priorities in primary care – Burnout of staff

‘We are just pushing numbers’ (Clinic Manager)

‘Quality care is really not ensured because people are trying to get through numbers…. If you don’t have the adequate staffing then it demoralises people and they can’t cope with the demands’ (Senior Manager)

– Poor management ‘From top management to the ground there are no

systems’ (Nurse)

‘The referral system, it is a nightmare, it really is a nightmare’ (Doctor

Experiences Joburg PHC

• Role of doctors– Deep doctors-nurse conflicts

‘Management always took an attitude …the doctor belonged to the consulting room. We never included him…. … and that’s why sometimes that cooperation we had with our senior clinicians we have lost it completely. It was never so bad’ (Senior Manager)

– Help ‘push the queues’‘Their role needs to be clarified because this is the PHC setting and we need to push the queues’ (Nurse)

– Role: Referrals, Training, Research & Administration

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Experiences Joburg PHC

• Family Medicine– Initial confusion

‘At primary level, primary (family) medicine is actually not a new thing. …. My issue at primary level is that the nurses are the backbones of the primary healthcare service’ (Senior Manager)

– Useful‘We should integrate the family medicine philosophy in our primary healthcare approach.’(Senior Manager)

– Re-organise the system‘I think the whole system should belong to them, I mean, they should be in charge of it’ (Intern)

COPC Project & Difficulties

• HR Model (with strong task-shifting)– 1 Dr– 3-4 Nurses– 10 CHWs– 10 000 population

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COPC Project & Difficulties

Primary Care Service

Re-orientation

Community Orientation, with CHWs

Communication, ‘one person - multiple

communities’

Inter-sectoralstakeholder collaboration

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• CHWMapping,

Registration& Screening

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• Integrated PHC

clinic services with EHR

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• Stakeholder Collaboration“Health in all

Policies”

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• Communication

in new social

identities

COPC Project & Difficulties

• Models from 2009 • Mofolo / Rosettenville

• Training/Rollout – Sept 2011-June 2012– 20 sites in City of Jhb– 300 CHWs– 7 Nurses– 35 000 people

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COPC Project & Difficulties

COPC Project & Difficulties

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COPC Project & Difficulties

COPC Project & Difficulties

• Challenges– PHC Re-engineering / MWPHCOT

• Bureaucratic interpretation• Public health screening programme• Dr shortage vs nurse-doctor conflict• Agendas

– Management

– Politicians

– Stopped COPC / evaluate MWPHCOT

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NHI & GP-led care

• Public-Private problems in SA• NHI in SA

– Public spend: R128b in 2011 �R255b 2025

• PHC Re-engineering– PHC Outreach Teams– Community Practices– Challenges in Joburg:

• ‘Doctor-shortage’

• Urban elites / Specialism

• Nurse-Dr conflicts

• Poorly trained CHWs

NHI & GP-led care

• Study in 2011• How do GPs in SA relate to NHI, capitated

service and contracting?• Online survey of 598 solo GPs from 9000

in SA• Offered a contract proposal of 10 000 list

size at utilisation of 3 pa

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NHI & GP-led care

• Ambivalence to NHI• Add 4.3 staff (1.4 PHC nurse/doctor, 1.6

nurse and 1.3 admin) to current 2.5 staff (dr + 1-2 admin)

• Price for consultation/x-ray (excl. meds/Ix) was R4.03m vs. R3.92m pa Metro costs

• 37% improvement in income for GPs• R17b (of R128b) + 5000 GPs to cover SA

population of 50m

NHI & GP-led care

• Risks– Contract– Utilisation

• Risk management– Preventive / promotive health– Improve management with task-shifting

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Conclusions

• African ProblemsAND

• African Solutions

• Joburg– Offers insight into African future

Comments/Questions?

FOR MORE:•Dr. Shabir Moosa, Department of Family Medicine, Johannesburg Health District, University of Witwatersrand, Johannesburg, 2193, SA•Email: shabir@drmoosa.co.za

FUNDING :•HURAPRIM (EU FP7-AFRICA-2010) grant agreement no. 265727.