By some measures - healthy life expectancy, obesity and depression, among others - South Africa is the unhealthiest country on earth. That's a sobering fact to consider. How has the country got here? To what extent can its unenviable position be regarded as a failure of primary health care?
Primary health care can refer to the care offered by general practitioners or primary care nurses at your local clinic. But there's more to it than that. Primary health care is underpinned by a vision. This sees health as an essential ingredient in the social foundation of society. It recognises that health is also interdependent on other ingredients: food, education, clean water, energy, social equity, safety, income and housing.
The healthy space for humanity to flourish is between this solid social foundation and our ecological ceiling, as issues such as climate change may also impact on health. Primary health care, then, requires a whole-of-society approach and is not just about health services.
South Africa is struggling with many of these issues. This means that in the broadest sense, the country has failed at delivering primary health care.
While those in the health care sector can't fix all the interrelated issues I've described, they can address the quality of primary care.
So how can this be achieved? Despite a failure to adequately address the broad social and environmental determinants of health, South Africa has the potential in its current policy to improve primary care in these three areas. But policies on paper are not enough. These must be properly implemented.
Access to health care
About 80% of South Africa's population depends on the public sector's primary care services. But access to this primary care in the public sector is often limited by the sheer number of patients. It's also restricted by opening times that do not cater for people who are working or become sick during evenings or on weekends.
South Africa has developed a policy to implement National Health Insurance (NHI). This would ensure improved access to primary care for the whole population. However, many general practitioners in the private sector are worried that the government will not be able to effectively implement and efficiently manage NHI at scale. Access is also not enough. The care that's offered must be of a good quality.
The NHI proposals are not the only plans that have been developed to try and provide good primary care to all South Africans. The discipline of family medicine is doing a great deal in this regard. Family physicians are qualified doctors that have completed additional training to become specialists in family medicine and primary care. Despite being slower on the uptake, South Africa is now finally seeing family physicians entering the health system in increasing numbers and joining primary care teams. Their inclusion in these teams brings additional clinical skills, commitment to person-centred care, clinical leadership and improvement to the quality of care.
Ongoing care refers to the continuity that patients have with their primary care providers over time. This continuity is based on a trusting relationship between primary care providers and their patients and an accumulated knowledge of the person.
A recent study of both nurses and doctors in Cape Town found that providers failed to even greet patients in more than 60% of consultations. In 90% of consultations, they made no attempt to understand the patient's perspective. This poor provider-patient relationship is a fundamental problem that fuels poor clinical outcomes, poor adherence to medication, patient dissatisfaction, litigation and a lack of job satisfaction among providers themselves.
In Cape Town as many as 76% of doctors in primary care are suffering from burnout. The symptoms include depersonalisation: they no longer see patients as people. It is clear that the health system needs to transform to be more people-centred - for both carers and cared for alike. Again, the inclusion of family physicians in the health system can help with this.
A renewed focus on community-orientated primary care is also important. This approach changes primary care: rather than health workers sitting in a clinic and waiting for people to ask for help, health workers in the community pro-actively prevent disease, promote health and identify people at risk. This has worked very well in other middle-income countries like Brazil.
South Africa is taking some steps in this direction, too. Cape Town's metropolitan district health services are busy learning how to implement community-orientated primary care at scale over the next few years.
Thinking about the community as a whole and not just individual patients is a game changer. Health workers can identify and prioritise community health needs, and address the social and environmental determinants of health in an inter-sectoral approach with other stakeholders in that community. Community participation in this process is also a key principle. If South Africa can implement this approach effectively, it could transform the health services - and the health of local communities.