A scoping review on family medicine in sub-Saharan Africa: practice, positioning and impact in African health care systems

The scoping review protocol was conducted according to a pre-determined protocol [27]. Medical subject heading (MeSH) terms and search strings were agreed upon (see Table 4) [27, 28]. The databases searched in March and April 2018 are shown in Table 5.

Inclusion criteria for articles identified in the search strategies are shown in Table 6. Selected articles had to meet criteria 1 to 3, and optional criteria 4 or 5 as shown in Table 6. All types of articles from peer-reviewed journals were considered, but grey literature was not searched. Only articles published in English since the year 2000 were included. Publications before 2000 were few and less relevant to current health systems. Research articles that looked at delivery of care for specific diseases were excluded.

Articles were initially selected using the title and abstract. Each of the team members focused on one of the search strings from Table 4. The first author reviewed all articles that were identified in the individual searches, taking out duplicates and creating the final list of selected articles. A total of 103 articles, with available abstracts, was obtained. Each of the researchers then received a list of approximately 20 articles to read the full text and reviewed if they met the inclusion and exclusion criteria. When the full text was not found or articles did not meet the defined criteria, they were excluded. Snowballing, retrieving relevant cited articles from the identified articles, was done until no more related articles were found [29]. Figure 1 shows the flow of article selection and the numbers that were in- and excluded [30].

Characteristics of the articles (such as authors, title, year of publication, journal, country focus, type of paper, aim, study population, methodology and key findings) were then extracted into a matrix. As this was a scoping review, no critical appraisal of the quality of the included articles was done [27]. The matrix was then used to analyse the characteristics of the included articles and interpret the key findings in order to answer the research questions.

Key findings of these articles were compiled into a narrative which was presented in Gauteng, South Africa, April 2018, where a 3-day Primafamed workshop took place, with support of Stellenbosch University and Ariadne Labs. The Primafamed workshop also included the researchers from the other scoping reviews. Altogether, 15 participants came together to look at the findings of the scoping review and to validate the scoping review process. The knowledge gaps exposed by the scoping review were discussed. Following this meeting, the researchers completed the analysis and collaboratively wrote this article.

Only articles written in English were accepted. This limited the search mainly to articles from Anglophone Africa. Any articles from Francophone Africa and countries with other languages such as Portuguese, Arabic and Amharic were not included; therefore, information related to the development of FM in these countries was limited to English articles. The search focused on peer-reviewed articles from academic journals. Grey literature such as reports from ministries of health, non-governmental organizations and PhD theses were not included; therefore, there may have been additional evidence pertinent to the scoping review that was missed.

The implementation of FM was usually reflected in the way the postgraduate (PG) training of the discipline is delivered. Therefore, next to the actual implementation, some aspects of the delivery of the training will be provided.

The first developments in FM in SSA took place in South Africa and Nigeria, later East Africa and Ghana. Following this, most Southern African countries also introduced the discipline. There is no single model for FM. Each country had a unique set of circumstances that informed the most appropriate path for the development of FM, as shown in Table 9 [7, 17, 18].

Most postgraduate FM training programmes in SSA were inspired by the development of FM in Western Europe and North America. The literature, however, recognizes that the design of FM in HIC may not be applicable to SSA, as the pattern and distribution of diseases, shortages of healthcare workers and the rural location of the population are quite different [49]. FM training in SSA includes extended procedural skills especially for life-threatening medical, obstetric and surgical conditions in low-resource settings [32, 49].

Development of FM, with adaptation to local contexts, has taken place in many SSA countries, albeit in different ways and stages of development, as shown in Table 9. The Primafamed network showed that between 2008 and 2010, the developmental stage of FM training and the acknowledgement of the discipline in the different HS improved substantially for each of the participating universities [18].

In a survey on understanding FM in SSA, some key leaders saw FM as a specialized PHC physician. However, most saw African FPs mainly as hospital specialists, a combination of the four major clinical specialties or as stepping stones to later specialization, rather than a positive career option in its own right [5].

FM in SSA ought to improve health outcomes, reduce costs, provide skilled leadership for PHC teams and improve the recruitment, retention and distribution of generalist physicians [57].

There is a clear perception among co-workers that FPs in South Africa are making an impact on quality of care and population health status [62]. In instances where FPs have functioned well, the PHC team has begun to function more coherently [62]. Reflections from district managers suggest that FPs make a significant impact on the quality of clinical processes and health system performance [63]. FPs have the potential to develop a sense of responsibility for specific communities and to connect higher management principles with local community needs. They also have been able to broaden the scope of practice as they received a comprehensive training, covering biomedical, psychological and social issues. As a result of the improved quality and scope of practice, FPs may have impacted on referral rates and enabled more patients to be managed in the district, saving money at other levels [31]. This also saved patients time and money, as previously people would have had to travel to a referral hospital [39].

Student perceptions in different countries also seem to be positive. Nigerian medical students believed FM was relevant as a specialty in the healthcare system, although most students preferred another discipline for their career choice [42]. The majority of first year undergraduate students at the University of Ghana perceived FPs to be capable of providing total health care for 85–95% of patients and also to reduce overall costs of care [44].

A FP impact evaluation tool was developed in South Africa and used in a national survey. This survey questioned managers, doctors, nurses and other health professionals working with FPs. Family physicians were perceived to have a high impact in their roles as clinicians, consultants, clinical trainers, leaders of clinical governance and champions of community-oriented primary care and a moderate impact as capacity builders of the health care team. This impact was perceived to be significantly more than medical doctors (without specialty training) across all six key roles [64]. These key roles for FPs were agreed upon in South Africa as shown in Fig. 5 [39, 64]. This higher perceived impact was found in district hospitals and primary care facilities as well as urban and rural areas. An additional study found evidence that FPs were making a significant impact at district hospitals, particularly in child health care [65]. Surprisingly, this same study found that community health centers without FPs had better continuity and coordination of care, although this might be due to the confounder that FPs were placed at larger centers with a higher workload [65]. There was no correlation between FP supply and routinely collected district health indicators as numbers of FPs were still very small (0.3 per 10,000 population in the public sector) [65, 66].

A huge challenge is that FM is still fairly unknown, and due to low numbers, there is low visibility. In many countries FM is still in its early stages of development and there is little opportunity to assess strengths and weaknesses at scale [67]. However, policymakers, funders and other disciplines require more evidence to shift to a more positive attitude [5]. Roles and responsibilities of FPs are not always clear, neither is their exact place in HS, leading to difficulties with incorporating the discipline into health policy [5].

A continuous challenge around the continent is training sufficient FPs to show a significant impact on health outcomes [57]. Key stakeholders can sustain or sink the development of a programme and support is context dependent. While in several countries, such as South Africa, Nigeria, Kenya, Ethiopia and Ghana, it appears that decision makers find value in FM, other stakeholders (Table 10) have different perspectives on the discipline. In a number of other countries, such as Rwanda and Tanzania, support for its development is almost absent [4].

A 2010 study among FM educators revealed many challenges such as a need for more FP trainers, funding, resources, career opportunities, buy-in from hospital-based specialists and acceptance of FM as an essential discipline by authorities to train the required critical mass [18, 68].

Within the discipline in SSA, there is some debate on whether FM should move away from a hospital-based focus towards a more primary and community-based focus (Table 11) [69, 70].

Several strengths of the discipline have been identified. The creation of specialist FP posts within the public sectors of countries in Western and Southern Africa has established a career pathway with the same salary scale as other specialists in the academic teaching hospitals. This has enabled FM to attract good candidates and to start to transform the perception that only people without academic ability or ambition are attracted to careers in district health services. The district health services have seen FPs make a strong contribution in the area of clinical governance [39]. Key leaders saw the capacity to provide training, mentorship, supervision and leadership as some of the strengths (Table 12) [5].

FPs are seen to be a communicator, collaborator and consultant strengthening care delivery. They are placed between non-physician primary care providers (such as nurses in the health centres) and specialist physicians at higher levels of care. The FP’s niche is often said to be in the community, but they are usually placed at other levels of care due to low numbers of human resources for health [6]. This tension between concept and reality is a challenge for the identity of the discipline. FPs are employed at all levels of care, depending on the country’s health system, available other human resources and the local needs, in primary, secondary and even tertiary care [36].

Key leaders saw FPs as “all-round specialists” (or expert-generalists) at smaller hospitals, in the absence of other specialists [5]. In most SSA countries, FPs are deployed in the framework of the district health system, which includes primary care facilities and district hospitals in both rural and urban areas (Table 9) [39]. The skills gap at district hospitals, often in rural or remote areas, was a compelling argument for the inclusion of FPs in the South African health system as these hospitals were not likely to sustain or attract other specialists [39].

The 2009 Rustenburg consensus (Table 8) related the roles of FPs in SSA to “a comprehensive set of skills adapted to the circumstances, local needs, available resources, facilities and the competency and limitations of the practitioner” [11]. Due to the different interpretations of the practice, some argue that “searching for a role-based common definition is ultimately insufficient” [8].

The model that emerged in South Africa required the FP to work at district hospital and in PHC, with the key roles as shown in Fig. 5. As care providers, they needed to be able to manage the majority of patients presenting to the district hospital and health centres, while as consultants to the inter-professional teams they actually saw the more complex medical problems. As capacity builders, they delegated tasks and responsibilities, while giving support and training to other members of the team. As clinical trainers, they provided training and supervision to the resident FPs, interns and medical students. As leaders of clinical governance, they led the teams in improving quality of care and patient safety, while as champions in COPC they supported the PHC teams in engaging with local communities to improve population health [15, 39, 71].

In West Africa, FM roles included PHC that could be in the home or primary care facility, with a focus on family-oriented primary care as well as in secondary or tertiary care hospitals [40, 72]. FPs were also placed in roles as clinical managers and medical superintendents throughout SSA, where they would manage systems, finances, schedules and patients and work as “agents of change” [6, 13, 43].

In many countries, the definition of roles is still “work in progress” [48, 50]. In Ethiopia for example, roles and responsibilities have not yet been clearly defined. FPs are expected to be care providers in the primary and secondary care level and act as health managers and team leaders [57].

Despite the overall intuitive consensus of FM being comprehensive and holistic, there tend to be two major directions. One direction, due to low human resources and significant skills gaps, sees the need to support district hospitals with outreach from there to PHC and the community [8]. FPs, particularly in rural areas, need to have additional training in obstetrics, surgery, otolaryngology, ophthalmology and child health and mental health as “rural family medicine training in Africa should continue to include skills necessary for secondary health care at the district level until all developmental indices, including medical manpower, has engulfed the vast rural communities in these countries” [70]. In the other direction, FPs are seen as supporting and being part of PHC teams in the community, with a focus on COPC [72]. In South Africa, the national position paper embraces the need to train and deploy FPs in both ways throughout the district health services and not to choose between these options [73].

During a 2016 workshop on exploring future scenarios of FM in the South African health care system, a group of 40 FPs came to three possible scenarios (Table 13), all depending on the direction policymakers would decide upon. They identified the need for increased advocacy for the discipline, especially in rural areas, and to increase research evidence of the contribution of FM to the health system [15].