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Overcoming challenges in primary care education in South Africa

South Africa achieved democracy in 1994 and for the first time committed itself to make primary healthcare the cornerstone of the health system for the whole population. The new government inherited a health system that was fragmented along racial and geographical lines, had inadequate infrastructure and was deeply inequitable. The incoming president immediately announced that primary healthcare would be free for mothers, children and indigent people, which increased demand on an already fragile and poorly functioning system. In this situation the only cadre of health workers large enough was nurses and therefore the primary care system became nurse-driven. Today 80% of all consultations in primary care are with nurses.1 In addition the health sector was challenged to find ways to deal with the rapidly growing epidemic of HIV and TB in the face of the government’s HIV denialism and initial failure to provide anti-retroviral treatment. The burden of disease from HIV and TB remains disproportionately higher than the other three significant burdens of interpersonal violence and trauma, poor maternal and child health and emerging non-communicable chronic diseases.2 Currently South Africa has only 3.7 medical practitioners and 2.0 specialists per 10 000 people.3 These are also inequitably distributed with a preponderance being in the private (medical insurance-funded) sector as well as in urban areas. It should be noted that in the South African public sector generalist care by doctors includes service at district hospitals, often in rural and remote locations, as well as in primary care.4 Over the last 20 years much progress has been made in establishing a district health system with clear boundaries and management structures as well as renovating existing and building new infrastructure. In the last few years the government has developed a long-term vision of universal coverage through national health insurance.5 This policy requires that the quality of public sector services be improved so that they would be acceptable to the whole population and that a large portion of the resources currently spent in the private sector (60% of all expenditure on healthcare for 16% of the population) be integrated into the health system for everyone. The human resources for primary healthcare are obviously a critical ingredient in achieving this vision. Many different health professionals are involved in delivering primary healthcare, but for the purposes of this article we will focus on the primary care education of four key groups: doctors, nurses, community health workers and clinical associates.