Doctoral Degrees (Family Medicine and Primary Care)

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    Evaluating the effects of a training programme in mindfulness based interventions in South Africa
    (Stellenbosch : Stellenbosch University, 2023-12) Whitesman, Simon; Mash, Bob; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY: The training of teachers of contemporary mindfulness-based approaches requires a range of competencies to be developed, embedded within which is the implicit paradox that learning and sharing mindfulness is a life-long journey, while at the same time is always present centered. The capacity of a teacher of this approach to embody the immanence of mindfulness is fundamental to this process. Thus training of teachers involves a complex interplay of experiential learning, theoretical understanding, group enquiry and periods of silent practice, both self-directed and guided. At its essence, mindfulness is the momentary knowing of the phenomena moving through the present moment, and is, as such, a subjective experience. In general the training of mindfulness-based teachers over the last two decades has been through institutions in developed countries. At the same time much of the research in the field has emerged from similar regions. While mindfulness as a practice and ethos is consistent irrespective of context, it is nonetheless important to consider that context influences the way in which mindfulness is effectively and skillfully shared, given the particular psycho-social, economic and demographics dynamics of a given country. The research presented in this dissertation is based on the experience of trainee teachers and graduates of a two-year, university-level training in mindfulness-based interventions (MBIs) in South Africa, considered a low-middle income country. As such the context is different from the prevailing regions where most teacher training is currently offered. The focus in this dissertation is primarily on the experience of those undergoing the training as the source of data. The research arc can be considered an inward-outward movement, tracking aspects of the learning journey during the training through to the sharing of mindfulness in communities, which represent many of the enormously challenging dimensions of life for a majority of South Africans. The methodological approach is a mixed-methods one, in which quantitative data using standardised scales as well as surveys are considered alongside qualitative analysis from various data sources, such as focus group and individual interviews. The findings and implications that emerge from this research are applicable to both mindfulness-based pedagogy as well as the sharing of mindfulness in diverse communities, in which skillful adaptation and trauma sensitivity are central features.
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    The effect of substance uses on antiretroviral therapy adherence among people living with HIV in Mthatha, Eastern Cape
    (Stellenbosch : Stellenbosch University, 2023-12) Kaswa, Ramprakash; De Villiers, Marietjie; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY: INTRODUCTION: Around 13.3% of South Africa's population use illicit substances during their lifetime. The prevalence of substance use disorders is significantly higher than the global average. The increasing number of people living with HIV who use substances is a serious threat to the ongoing HIV epidemic and could compromise the continuity of care. Although the number of individuals infected with the virus has decreased since implementing the universal test and treat program in the country, co-infection remains a significant issue. In South Africa, the prevalence of hepatitis B virus infection is high among people living with HIV. The success of treatment is determined by how well an individual follows their treatment. Unfortunately, people who use substances are more prone to experiencing suboptimal adherence. Although the exact effects of their use on the adherence rate are unknown, it is believed that they could significantly impact the quality of care. As the gatekeepers of health, primary care providers are responsible for providing the best possible care to patients. They have a responsibility to identify and manage individuals who use substances. In addition, primary care providers can also help individuals reduce their use of substances by integrating them into their regular health care. This process can help them provide effective treatment and prevent them from developing substance use dependency. The researcher conducting this study is motivated by the lack of co-morbidity data and the poor adherence to ART among people living with human immunodeficiency virus in primary healthcare settings. The study aimed to evaluate the co-morbidity of HIV and substance use and their management in the primary healthcare settings in Mthatha, Eastern Cape.
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    An evaluation of the quality of service delivery in private primary care facilities in Nairobi, Kenya
    (Stellenbosch : Stellenbosch University, 2021-12) Mohamoud, Gulnaz; Mash, Robert; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY : Introduction: The World Health Organization (WHO) states that well-functioning primary health care (PHC) should be the foundation of effective health systems. Primary care (PC) is a subset of PHC, and is a “key process in the health system that supports first-contact, accessible, continued, comprehensive and coordinated patient-focused care.” In sub-Saharan Africa (SSA), health systems still face many challenges and PC remains poorly functioning in many countries. Measuring the quality of PC service delivery and identifying the strengths and weaknesses will help policy makers and implementers improve PC and achieve better health outcomes. Kenya’s Health Policy 2012-2030 aims to promote higher quality and better access to services, however, “quality” remains a major challenge. The private health care system provides 52% of all health care services and may have a bigger role to play in the future. In Kenya, most of the PC in the private sector is provided by general practitioners (GPs), the majority of whom do not have specialist postgraduate training. Due to diversity and fragmentation of the private PC system, there is little data on the strengths and weaknesses of key elements of PC service delivery. Hence, the new knowledge from our study is aimed at kick-starting future evaluations leading to a long term improvement in quality in service delivery in line with the existing and new health needs that are anticipated over the next few decades. The main aim of this study was to evaluate the quality of service delivery in PC facilities by GPs in the private sector in Nairobi, Kenya. Five studies were performed to measure the key elements of quality PC: first-contact access, coordination, continuity, comprehensiveness and person-centredness. The abstracts for the five articles are provided below. Article 1: Perceptions regarding the scope of practice of family doctors amongst patients in primary care settings in Nairobi. Background: Primary care is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by general practitioners. Little is known about how patients perceive their capability. The aim was to assess patients’ perceptions of the scope of practice of GPs working in private sector PC clinics in Nairobi and their awareness of the new discipline of family medicine. Methods: A descriptive survey using a structured, self-administered questionnaire in eight private sector PC clinics in Nairobi. Simple random sampling was used to recruit 162 patient participants. Results: Of the participants, only 30% knew the difference between FPs and GPs. There was a high to moderate confidence (>60%) that GPs could treat common illnesses, provide lifestyle advice, offer family planning and childhood immunisations. In adolescents and adults, low confidence (<60%) was expressed in their ability to manage tuberculosis, human immunodeficiency virus and cancer. In the elderly, there was low confidence in their ability to manage depression, anxiety, urinary incontinence and diabetes. There was low confidence in their ability to provide antenatal care and pap smears. Conclusion: Patients did not perceive that GPs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing family physicians. Article 2: Evaluation of the quality of service delivery in private sector, primary care clinics in Kenya. Background: The quality of PC service delivery is an important determinant of clinical outcomes. The patients’ perspective is one significant predictor of this quality. Little is known of the quality of such service delivery in the private sector in Kenya. The aim of the study was to evaluate the quality of service delivery from the patient’s perspective in private sector, PC clinics in Nairobi, Kenya. Methods: The study employed a descriptive cross-sectional survey by using the General Practice Assessment Questionnaire in 378 randomly selected patients from 13 PC clinics. Data were analysed using the Statistical Package for Social Sciences. Results: Overall, 76% were below 45 years, 74% employed and 73% without chronic diseases. Majority (97%) were happy to see the general practitioner (GP) again, 99% were satisfied with their consultation and 83% likely to recommend the GP to others. Participants found the receptionist helpful (97%) and the majority were happy with the opening hours (73%) and waiting times (85%). Although 84% thought appointments were important, only 48% felt this was easy to make, and only 44% were able to access a particular GP on the same day. Overall satisfaction was higher in employed (98%) versus those unemployed (95%), studying (93%) or retired (94%) (p < 0.001). Conclusion: Patients reported high satisfaction with the quality of service delivery. Utilisation was skewed towards younger, employed adults, without chronic conditions, suggesting that PC was not fully comprehensive. Services were easily accessible, although with little expectation of relational continuity. Further studies should continue to evaluate the quality of service delivery from other perspectives and tools. Article 3: Evaluation of the quality of communication in consultations by general practitioners in primary care settings, Nairobi, Kenya. Background: Primary care is the starting point for patients seeking health care. High quality PC requires effective communication to support person-centredness, continuity and coordination of care, and better health outcomes. In Kenya, there is very scanty knowledge about the quality of communication in consultations by GPs in the private sector. Hence, the aim was to evaluate the quality of communication in consultations by GPs. Methods: Descriptive, observational cross-sectional study of 23 GPs consultations in 13 primary care facilities in Nairobi. One consenting adult patient was randomly selected from the GP’s list for an audio recording of their consultation. Audio recordings were assessed using the Stellenbosch University Observation Tool. The overall score for each consultation was obtained out of a maximum of 32. Data was analysed using the Statistical Package for Social Sciences version 25. Results: The median age of the GPs was 30.0 years (IQR: 29-32) with a median of 3-years’ experience after graduation (IQR=3-6). Median consultation time was 7.0 minutes (IQR=3-9). Median score of the consultations was 64.3% (IQR: 48.4-75.7). The GPs fully performed skills in gathering information, making a diagnosis and in its explanation and management. The GPs did not make an appropriate introduction, nor explore the family and social context or patient’s perspective. Patients were not fully involved in the shared decision making process. Safety netting and closure was not fully addressed. There was a significant positive correlation between the consultation scores and duration of the consultations (r=0.680, p=0.001). Conclusion: Consultations were brief, with low-to-moderate complexity and had a biomedical approach. Training in communication skills with the goal of providing person-centred care will result in higher quality consultations and PC. Article 4: The quality of primary care performance in private sector facilities in Nairobi, Kenya. Background: Integrated health services with an emphasis on PC are needed for effective primary health care and achievement of universal health coverage. The key elements of high quality PC are first-contact access, continuity, comprehensiveness, coordination, and person-centredness. In Kenya, there is little information on these key elements and such information is needed to improve service delivery. This study aimed to evaluate the quality of PC performance in a group of private sector clinics in Nairobi, Kenya. Methods: A cross-sectional descriptive study adapted the Primary Care Assessment Tool (PCAT) for the Kenyan context and surveyed 412 systematically sampled PC users, from 13 PC clinics. Data was analysed to measure 11 domains of PC performance and two aggregated PC scores using the Statistical Package for Social Sciences. Results: Mean primary care score was 2.64 (SD=0.23) and the mean expanded primary care score was 2.68 (SD=0.19), implying poor overall performance. The domains of first contact-utilisation, coordination (information system), family-centredness and cultural competence had mean scores of >3.0 (acceptable to good performance). The domains of first contact (access), coordination, comprehensiveness (provided and available), ongoing care and community-orientation had mean scores of < 3.0 (poor performance). Older respondents (p=0.05) and those with higher affiliation to the clinics (p=0.01) were more likely to rate PC as acceptable to good. Conclusion: These private sector clinics in Nairobi had a poor overall performance. Performance could be improved by deploying family physicians, increasing the scope of practice to become more comprehensive, improving access after-hours and marketing the use of the clinics to the practice population. Article 5: General practitioners’ training and experience in the clinical skills required for comprehensive primary care, Nairobi, Kenya. Background: Quality service delivery in primary care requires availability of motivated and competent health professionals. There is a paucity of evidence on the ability of PC providers to deliver comprehensive care and no such evidence is available for GPs practising in the private sector in Kenya. Therefore, the aim was to evaluate the GPs’ training and experience in the clinical skills required for comprehensive primary care. Methods: This was a cross-sectional descriptive survey using an adapted questionnaire, originally designed for a national survey of PC doctors in South Africa. The study evaluated self-reported clinical skills performance of all 25 GPs at the 13 PC clinics in Nairobi. Results: GPs were mostly under 40 years with less than 10 years of experience with an almost equal gender distribution. Categories with moderate performance included adult health, emergencies, communication and consultation, child health and clinical administration skills. Whilst, weak performance included surgery, ear-nose-and-throat, eyes, women’s health and orthopaedics. The GPs lacked training in specific skills related to proctoscopy, contraceptive devices, skin procedures, intra-articular injections, red reflex test and use of a genogram. Conclusion: Majority of the GPs were young with few years of clinical experience after graduation. GPs lacked training and performed poorly in some of the essential and basic skills required in PC. The gaps highlighted the need for training and broadening the model of care to offer a more comprehensive package. Training in family medicine can also be offered, which aims to deliver an expert generalist and attention should be given to health systems design and the necessary inputs required to support more comprehensive care. Final conclusions: The patients visiting these private clinics consisted mostly of young to middle-aged adults, who were well-educated and employed. Most of the patients did not have any chronic conditions and reported their health status as good to excellent. Overall ratings showed high satisfaction in relation to first-contact utilisation, services by the receptionists, the regular opening hours of the clinics and short waiting times. Even though patients expressed the desire to book appointments via the phone, access to this service was limited. Access to a particular GP by phone or for emergency consultations was also limited. Utilisation and long-term affiliation with the practice was reported as good, suggesting reasonable longitudinal continuity. Patients expressed high satisfaction with care enablement and had confidence in the GPs’ honesty and trustworthiness. Informational continuity was also strong, although relational continuity less so, as patients did not express a commitment to any particular GP. Patients had limited expectations of the comprehensiveness of services offered by the GPs. Patients also reported low confidence in the GPs’ ability to manage and provide care for many core aspects of PC. The clinics were not comprehensive in the range of services available and provided. The gaps were evident in areas such as chronic conditions, antenatal care, advice for lifestyle modifications, women’s and men’s health screening. The facilities did not offer a complete primary health care team such as access to a social worker, physiotherapist, counsellor or dietician. There was poor performance by the GPs in some of the essential and basic skills required to offer a more comprehensive package of care in areas such as women’s health, ear, nose and throat, ophthalmology and orthopaedics. The information system supported care coordination and was excellent due to an integrated electronic health record system and contributed to patient satisfaction. GPs conducted brief consultations of low-moderate complexity and showed a substantial commitment to parallel coordination of care within the clinic. However, the quality of sequential coordination was reported as borderline and patients were rarely referred to the hospital. Patients felt confident in and satisfied with brief bio-medical consultations. GPs were able to obtain sufficient biomedical information, make an appropriate diagnosis, as well as formulate and explain an appropriate management plan. However, there were gaps in the provision of whole-person medicine related to the patient’s perspectives and context, exploration of patient’s psychosocial and occupational history, shared decision making process, provision of safety netting and closure. Patients, however, felt that GPs were sufficiently family-centred and culturally competent. The combined observations of all these studies confirm that this private health care system is not offering fully accessible, continuous, coordinated, comprehensive and person-centred primary care. A number of recommendations are made to improve the quality of PC.
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    How to transform the workplace environment to prevent and control risk factors associated with non-communicable chronic diseases
    (Stellenbosch : Stellenbosch University, 2019-04) Schouw, Darcelle; Mash, Robert; Kolbe-Alexander, Tracy; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY : The underlying causes of premature morbidity and mortality in South Africa (SA) are related to unhealthy lifestyle behaviours, which are modifiable. Chronic non-communicable diseases (cardiovascular disease, respiratory disease, diabetes and cancer) are partly attributed to behavioural risk factors such as tobacco smoking, harmful alcohol use, physical inactivity and unhealthy eating, which if not controlled, results in an increase in metabolic risk factors. The workplace is highlighted as an important setting for the prevention of non-communicable diseases (NCDs). The work environment directly shapes employee health, and health behaviours, and acts as an accelerator or preventer of chronic disease. Very little research in the African context has focused on how to transform the workplace environment to prevent and control the risk factors associated with NCDs. The aim of the research was to design, implement and evaluate a workplace health promotion program (WHPP) to prevent or reduce the risk factors for NCDs amongst the workforce at a commercial power plant in South Africa. The objectives were to monitor changes in NCD risk factors in the workforce, as well as monitor sick leave absenteeism and evaluate the costs and consequences of the workplace health promotion program. The abstracts for the four articles presented for the doctoral degree are provided here. Article 1 Title: Risk factors for non-communicable diseases in the workforce at a commercial power plant in South Africa. Background: Non-communicable diseases (NCDs) account for more than half of annual deaths globally and nearly 40% of deaths in South Africa. The workplace can be an important setting for the prevention of NCDs. Objectives: The objectives of this study were to describe the prevalence’s of reported NCDs and previously identified risk factors for NCDs, as well as to assess risky behaviour for NCDs, and the 10-year risk for cardiovascular disease, amongst the workforce at a commercial power plant in the Western Cape province of South Africa. Methods: A total of 156 employees was randomly selected from the workforce of 1 743. Questionnaires were administrated to elicit self-reported information about NCDs, tobacco smoking, alcohol use, diet, physical activity and psychosocial stress. Biometric health screening included measurements and calculations of blood pressure, total cholesterol, random glucose, body mass index (BMI), waist circumference and waist-to-hip ratio (WHR). The 10-year risk for cardiovascular disease was calculated using a chart-based validated non-laboratory algorithm. Results: The study participants had a mean age of 42.8 (25-64) years; 65.2% were male. A quarter (26.0%) smoked tobacco, 29.4% reported harmful or dependent alcohol use, 73.0% had inadequate fruit and vegetable intake, and 64.1% were physically inactive. Systolic and diastolic blood pressure was raised in 32.7% and 34.6% of the study participants, respectively, 62.2% had raised cholesterol, 76.9% were overweight or obese, and 27.1% had abdominal obesity. Overall, 17.4% were diagnosed with hypercholesterolaemia, 17.7% with hypertension, and 16.2% with depression. Around one third (34.1%) had a moderate-to-high 10-year cardiovascular disease risk. Conclusion: The prevalence’s of both behavioural and physical risk factors for NCDs amongst the power station study participants were high. There is a need for effective workplace interventions to reduce risk for NCDs. The workplace is ideally suited for targeted interventions. Article 2 Title: Transforming the workplace environment to prevent non-communicable chronic diseases: Participatory action research in a South African power plant. Background: The workplace is an important setting for the prevention of non-communicable diseases (NCDs). Policies for transformation of the workplace environment have focused more on what to do and less on how to do it. The aim of this study was to learn how to transform the workplace environment in order to prevent and control the risk factors for NCDs amongst the workforce at a commercial power plant in Cape Town, South Africa. Methods: The study design utilized participatory action research (PAR) in the format of a cooperative inquiry group (CIG). The researcher and participants engaged in a cyclical process of planning, action, observation and reflection over a 2-year period. The group used outcome mapping to define the vision, mission, boundary partners, outcomes and strategies required. At the end of the inquiry the CIG reached a consensus on their key learning. Results: Substantial change was observed in the boundary partners: catering services (78% of progress markers achieved), sport and physical activities (75%), health and wellness services (66%), and managerial support (65%). Highlights from a 10-point consensus on key learning included the need for: authentic leadership; diverse composition and functioning of the CIG; value of outcome mapping; importance of managerial engagement in personal and organizational change; and making healthy lifestyle an easy choice. Conclusion: Transformation included a multifaceted approach and an engagement with the organization as a living system. Future studies will evaluate changes in the risk profile of the workforce as well as the costs and consequences for the organization. Article 3 Title: Changes in risk factors for non-communicable diseases associated with a Healthy Choices at Work program at a commercial power plant. Background: Globally, 71% of deaths are attributed to non-communicable diseases (NCD). The workplace is ideal for interventions aiming to prevent NCDs, however much of the current evidence is from high income countries. Objective: The aim of this study was to evaluate changes in NCD risk factors associated with a Healthy Choices at Work program (HCW) at a commercial power plant in South Africa. Methods: This was a before-and-after study in a randomly selected sample of 156 employees at baseline and 2-years. The HCW focused on catering, physical activity, health and wellness services and managerial support. Participants completed questionnaires on their participation in the HCW, tobacco smoking, harmful alcohol use, fruit and vegetable intake, physical activity, psychosocial stress and history of NCDs. Clinical measures included blood pressure, total cholesterol, random blood glucose, body mass index (BMI), waist circumference and waist-to-hip ratio. The 10-year cardiovascular risk was calculated using a validated algorithm. Data was analysed with the Statistical Package for the Social Sciences. Results: Paired data was obtained for 136 employees. Their mean age was 42.7 years (SD 9.7); 64% were male. The prevalence of sufficient fruit and vegetables increased from 27% to 64% (p<0.001), those meeting physical activity guidelines increased from 44% to 65% (p<0.001). Harmful alcohol use decreased from 21% to 5% (p=0.001). There were significant improvements in systolic and diastolic blood pressure (mean difference -10.2mmHg (95%CI: -7.3 to -13.2); and -3.9mmHg (95%CI: -1.8 to -5.8); p<0.001) and total cholesterol (mean difference -0.45mmol/l (-0.3 to -0.6)). There were no significant improvements in BMI. Psychosocial stress from relationships with colleagues, personal finances, and personal health significantly improved. There was a non-significant decrease of 4.5% in people with a high 10-year cardiovascular risk. Conclusion: The HCW was associated with significant reductions in behavioural, metabolic and psychosocial risk factors for NCDs. Article 4 Title: Cost and consequence analysis of Healthy Choices at Work (HCW) program to prevent non-communicable diseases in a commercial power plant. Abstract: The workplace is identified as an ideal setting for the implementation of a Healthy Choices at Work program (HCW) to prevent and control NCDs. However, given the limited resources assigned to workplace health promotion programs in LMIC, this study aimed to conduct a cost and consequence analysis using participatory action learning to improve the NCD risk profiles at low cost. Methods: Incremental costs were obtained from the activities of the Healthy Choices at Work program at the commercial power plant over a two-year period. A total of 156 employees participated in the intervention but the affect was experienced by all employees. An annual health risk assessment at baseline and follow up was included in the consequence of the study. Results: The total incremental costs over the two-year period accumulated to $3745 for 1743 employees. The cost per employee on an annual basis was $1 resulting in -10.2mmHg in systolic blood pressure, -3.87mmHg in diastolic blood pressure, -0.45mmol/l in total cholesterol, significant improvements (p=0.001) for harmful alcohol use, fruit and vegetable intake and physical inactivity. There was no improvement in correlation between sickness absenteeism and risk factors for non-communicable diseases. Conclusion: The cost to implement the multicomponent HCW programs was considerably low as was the significant consequences in transforming the workplace environment. Findings of this study will be useful for small, medium and large (SML) organisations, the national department of health, and similar settings in LMIC. Conclusion: The high prevalence of behavioral and metabolic risk factors for NCDs amongst participants at the power station resulted in the design of an effective WHPP to reduce risks. A Healthy Choice at Work program (HCW) included a multifaceted approach and was associated with significant reductions in risk factors for NCDs. The cost to implement the HCW program was low with significant consequences in transforming the workplace environment, which are useful findings for small, medium and large organizations.
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    Evaluating the impact of family physicians within the district health system of South Africa
    (Stellenbosch : Stellenbosch University, 2017-12) Von Pressentin, Klaus Botho; Mash, Robert J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY: The majority of the South African population are dependent on the public health sector in helping them deal with the quadruple burden of disease, consisting of HIV/AIDS and tuberculosis, maternal and child health problems, non-communicable diseases as well as trauma and violence-related injuries. The post-1994 South African government has embraced the global shift towards primary health care (PHC) as the vehicle for delivering quality health care to all. The health of communities is better in countries with strong PHC-centred health systems. Global evidence supports PHC delivered by primary care teams that include doctors with postgraduate training in family medicine (family physicians). However, the evidence on the contribution of family physicians (FPs) to strengthening health systems is mainly derived from high income countries. African leaders and policy makers are looking for local evidence on the potential role of FPs, as investment in the training and development of a new cadre of specialists in family medicine represents a significant financial commitment within the health system. According to a 2015 national consensus paper, South African FPs have six roles in the PHC team: care provider to patients, consultant to the PHC team (mainly nurses and doctors), champion of community-oriented PHC, clinical governance leader (focus on quality improvement), clinical trainer of students and registrars, and capacity building of the PHC team members. FPs are working in various aspects of the South African district health system (DHS), namely district hospitals, primary care facilities (health centres and clinics) and community based PHC teams (community health workers). The DHS consists of all health services relating to the health and wellbeing of a community within a defined geographic area (the health district). The discipline of family medicine was made a specialty in 2007 by the South African health professions council and resulted in re-structured training of FPs in keeping with the training model of other medical specialities. Graduates from this new training model have entered the DHS since 2011. These graduates are deployed in a heterogeneous manner in the different provinces, which reflect the uncertainty among policy makers and health managers on how best to use FPs in their districts. FPs represent a costly human resource investment in an environment dominated by vertical disease programmes and nurse-driven PHC services. This uncertainty together with the paucity of local evidence paved the way for anational study that was conceptualised in response to a joint funding call of the National Department of Health and EuropeAid in 2013, titled: “Strengthening primary health care through primary care doctors and family physicians”. This PhD research project represents one component of the overall project that aimed to evaluate the contribution of FPs to the DHS in South Africa. The study aimed to evaluate the impact of FPs within the DHS of South Africa. The study objectives are shown below: A. To describe the perceived impact of FPs in terms of their six roles within the DHS. B. To describe co-health workers’ perception of the impact of FPs compared to medical officers who had received no postgraduate training. C. To compare the perceived impact of FPs between metropolitan and rural districts, between facility types (district hospitals vs. primary care facilities), as well as by training programme model (graduation before and after 2011). D. To explore the perceptions of district managers regarding the impact of FPs in the following three domains: health system performance, clinical processes and health outcomes. E. To assess the influence of FPs at primary care facilities and district hospitals. The influence of FPs was evaluated in terms of two domains: health system performance, and quality of clinical processes across the burden of disease. F. To evaluate the impact of an increase in FP supply in each district (number per 10 000 population) on key health system performance indicators, key clinical processes and key health outcomes.