The results resonate well with the aim of this study: to understand the views of governmental and academic leaders in South Africa on the contribution of family medicine to the health system, and the challenges posed to implementation and human resource policy.
Whilst family physicians were seen as critical to the district health system there was ambivalence on their leadership role in the district health system and their ‘specialist’ status in the realm of generalism. National health policy was creating both threats and opportunities for family medicine. Whilst there was ambivalence and caution about teamwork, given existing human resource shortages, leaders’ views in South Africa were consistent with the findings of the previous study in Africa that family physicians are critical to the district health system (comprising clinics, community health centres (CHCs) and district hospitals). There was also consistency in lacking a strong positive understanding of generalists . This is evident in respondents’ hospital and ‘departmental’ bias with family physicians being directed towards staffing district hospitals due to human resource shortages. This is a major paradigmatic challenge in South Africa, and Africa, where reductionist specialism dominates the discourse . Family physicians in South Africa need to define and advocate generalism and family medicine as a set of values and principles in primary care used by the whole team, including family physicians.
Three key roles for family physicians emerged: providing expert generalist care to patients referred from nurses and junior doctors at clinics and community health centres, and thus reducing referrals to secondary or tertiary hospitals; taking responsibility for clinical governance and improving the quality of care; and providing support to community-oriented care. Roles were strongly defined around district hospital care, but did include an awareness of the need to shift towards community-orientated care, more so than African respondents  but consistent with African family physicians’ desires [16, 17]. Respondents saw the presence of family physicians as an opportunity to rearrange the health system, with National Health Insurance (NHI), to achieve both equity and quality. Higher expectations in terms of quality may not be far off with growing populations and urbanisation projected to make South Africa part of the largest middle class globally by 2060 .
Human resources appear to be the major challenge in implementation. Whilst respondents felt that developing a career path for generalist doctors was an important issue they seemed not to recognise the problems of working conditions that contributes strongly to the emigration of doctors . Respondents’ spoke of consolidating the development and training of family physicians, and shaping human resource policy to include family medicine. Respondents supported the African model of decentralized, scaled-up training (including private GPs) and undergraduate reform, consistent with African leaders . There were valid questions as to the skills required for family physicians in the NHI, especially team-based epidemiological management of populations. Whilst the idea of sub-specialisation might go against the concept of generalism it might also enable the wide skills range expected of family physicians in Africa (from community-oriented primary care to inpatient surgical/anaesthetic skills) to be better structured during training and better remunerated within governments occupation-specific dispensation (OSD) human resource system. As more family physicians are trained in a shorter time to work more widely as expert generalists in team-based ambulatory care (including a community health centre) in the NHI environment there are skills sets e.g. hospitalist care, rural health, management or education that could be deferred to longer elective training as ‘sub-specialties’ or special interests. This may be part of long term planning and may allow family physicians to serve a community more comprehensively without trying to be ‘all things to all people’. Revised models of training may be required, including undergraduate medical doctors and the range of members of the PHC team, to scale up for expected impact in South Africa .
Innovative solutions (e.g. including the large number of general practitioners (GPs) from the current private sector into a strongly regulated capitated public primary care system) can reduce the shortage of doctors in the public service  but team-based primary health care will still remain an important consideration. Family physicians need to be proactive in defining primary care service packages for primary care, staffing mixes and skills, including the range of members of the Primary Health Care (PHC) team. Family physicians also need to redefine the skills they require with a team-based approach, addressing the primary health care needs of a defined population for first contact care that is comprehensive, coordinated, continuous and accountable. These South African government and academic leaders recommended reviewing structure and roles within the primary health care team using business process re-engineering ideas. The World Health Organisation’s suggested tool for developing staffing norms, Workload Indicators for Staffing Needs (WISN), can be useful .
The strengths of the study were the wide geographic and professional variety of respondents, the strong adherence to the interview guide and the communication skills of two well-trained interviewers. The findings provide useful and transferable insights to the development of family medicine. A limitation may be that leaders more easily accessed by family physician researchers produced a more favourable view of family medicine.