Systems for the management of respiratory disease in primary care--an international series: South Africa.

INTRODUCTION: Progress to democracy in South Africa in 1994 was followed by the adoption of a primary health care approach with free access for all. State health facilities serve 80% of the population, and a private sector comprising general practitioners, specialists and private hospitals, serves the remainder. NATIONAL POLICIES AND MODELS: There are national prescribing guidelines for common diseases, and these specify the medicines on the Essential Drugs List that are available at primary care facilities for respiratory diseases including asthma, COPD, pneumonia and tuberculosis. EPIDEMIOLOGY: Asthma prevalence is average among children (13%) but morbidity is high. COPD rates are high owing to concurrent risk factors of smoking (in both men and women), occupational exposures, biomass fuel use and previous lung infections including tuberculosis. Tuberculosis and HIV are rampant, and together with pneumococcal co-infection account for considerable mortality. ACCESS TO CARE: Primary care facilities are within reach of most communities, but major barriers to care include loss of income, waiting times in clinics, cost of transportation, and inconvenient hours. FACILITIES AVAILABLE: The country is divided into districts each served by a hospital, several community health centres and many fixed or mobile clinics. The latter provide predominantly nurse-led care by nurse practitioners with additional qualifications. Some clinics and most community health centres are served by doctors. Referrals are made to secondary and tertiary hospitals served by specialists. FUTURE: Innovations to address staff shortages include the creation of the specialty of family medicine for physicians and development of the clinical associate who is trained to perform a limited clinical role, as well as in-service on-site training of nurses through programmes of integrated care for infectious and chronic diseases. There is an urgent need to address low staff morale and medical migration resulting from a decade of poor leadership and AIDS denialism.
CONCLUSIONS: The structures and policies for primary care in South Africa provide some grounds for optimism that services may begin to match the promise of quality care for all, but the burden of disease and resource constraints - particularly in terms of qualified personnel - mitigate against an early delivery of this promise.