Fewer than one out of three general practitioners contracted by one of the National Health Insurance (NHI) scheme’s pilot sites believe that the scheme will have a “discernible impact” on giving “previously underserved communities” better access to healthcare, according to a study published in the South African Medical Journal in November.
Researchers interviewed 55 of the 75 GPs who worked at one of 17 clinics in the NHI’s biggest pilot district, Tshwane, between April and June last year.
Many of the doctors said they wouldn’t be staying on “for a long time” because drug stock-outs, staff shortages and the “pressure of long queues” had reduced them to nothing more than “glorified nurses”.
“The reality of staff shortages [and a] lack of resources resulted in doctors simply providing the same routine services as nurses [such as] blood and urine tests, blood pressure monitoring [as well as] dispensing and packaging of medication,” the researchers have found.
The NHI has 11 pilot sites, one in each province and two in KwaZulu-Natal. It is aims to give all South Africans equal access to healthcare, regardless of their income and is “arguably the most radical health reform in the country’s history”, according to the researchers.
Because state hospitals and clinics are understaffed, the NHI also contracts GPs from the private sector to work part-time. “GPs are expected to [take on] complicated and chronic cases that are beyond the scope of nurse-led services and acting as gatekeepers by minimising onward referrals to higher levels of the health system,” the study explains.
But the government has been struggling to attract GPs. Its initial target to recruit 600 GPs in the first year was “drastically missed”, with less than 100 GPs signing contracts between 2013 and 2014. “Revised targets to have 900 GPs nationally contracted into [the] NHI by March 2015 equally failed, with approximately 200 out of the 8 000 private GPs in South Africa joining up”, the researchers say.
In the Eastern Cape’s OR Tambo district, only one GP had been contracted by 2015 and in the Northern Cape’s Pixley kaSeme district, only 10.
The Tshwane pilot site has recruited 75, the highest number of any district. But many of them might move on to other jobs because they say they work in clinics with “poor infrastructure, a lack of basic equipment such as sutures, sterile packs and syringes, and regular stock-outs of medication”.
“Doctors relayed feelings of ‘embarrassment’ and ‘powerlessness’ about their inability to provide decent care and many were scathing that the lack of resources undermined the NHI goal of reducing referrals to the hospital sector.
“There were repeated accounts of unnecessary referrals to hospitals for minor procedures that GPs should have been able to deal with if they had sufficient equipment,” the study has shown.
In some other provinces, the situation is even worse. Only 2% of health facilities in the Eastern Cape’s OR Tambo district have the “necessary equipment, medicines and space to allow private GPs to work in them — even if they were willing”, according to the study.
What is more, most of the doctors in the study were only prepared to work close to urban centres where their homes, children’s schools or private practises were located and “were therefore unwilling to travel to more distant, remote rural areas”.
The distribution of GPs among the six subdistricts of the Tshwane pilot site was therefore uneven, ranging from 20 to 25 GPs in subdistricts closest to Pretoria and to only five to six GPs in the subdistricts that were most distant.
Relatively few doctors had come from private practice, as envisaged in the white paper and many were newly graduated and had relatively little general practice experience. “Rather than recruiting from large well-resourced private sector practices as intended, this has largely been a reshuffling exercise within the public sector, with the majority of NHI recruits coming from public sector hospitals and primary care practices.”
The study concludes: “Given that most doctors in this study reported that they were providing basic nursing services rather than physician care, it is salient to question whether the placement of more GPs in under-resourced clinics can amount to a ‘re-engineered [health service]’. The findings from this study suggest that more time alone will not resolve the current problems … there must … be more engagement with the view and experiences of clinicians on the front line if the government’s agenda for healthcare reform is to be realised.”