Among all the debate and disagreement on National Health Insurance as a vehicle for South Africa’s universal health coverage aspirations, one idea remains uncontroversial: that Primary Health Care is the cornerstone to a resilient and sustainable health system. But this agreement is just the beginning. To achieve it South Africa’s Primary Health Care system will require massive investment of time and resources.
To understand our gaps, we must first understand what Primary Health Care is and is not. It is not the medical model (or Primary Care) which refers to the provider-patient relationship in healthcare. Instead, Primary Health Care also focuses on the broader social context surrounding the care relationship.
It includes the involvement of communities and broader society in its service design and in addressing the social, economic and environmental determinants of health. In addition, its delivery relies on a multidisciplinary care team tasked with delivery of integrated, continuous care that focuses on prevention and promotion of health in addition to cure, rehabilitation and palliative care.
While the South African public sector is partly designed on the principles of Primary Health Care, neither the public or private health sectors are delivering it as envisioned to achieve equity and access. Aside from addressing the upstream social determinants of health — an important aspect of Primary Health Care which we have written about previously — the four areas that need to be strengthened to achieve these outcomes include:
- Human resources and Primary Health Care-centric training.
- Strategic purchasing through capitation.
- Public-private sector service integration.
- Social accountability through community involvement.
What does SA’s current Primary Health Care workforce look like?
South Africa’s 2030 Human Resources for Health strategy estimates that a further 87,614 healthcare workers are needed across 24 cadres of health workers by 2025 in order to deliver improved Primary Health Care services. This represents a 75% increase in the 2019 numbers, which at that point stood at 115,126. Nurses are the bedrock of all health services making up 56% of all Human Resources for health; but a Primary Health Care workforce is also made up of many other health professionals, including district health specialists, medical officers, health and rehabilitation practitioners, mental health practitioners, and community health workers, to mention a few.
This Human Resources for Health strategy warned that the serious Primary Health Care shortages for many health professionals (including medical officers, professional nurses, nursing assistants, pharmacists and pharmacy assistants, psychologists, and dental personnel) would worsen by 2025 if nothing was done. We are now only a few months away from 2025 and this strategy has not been implemented. So it is impossible to meet the targeted increase.
Why don’t we train more healthcare workers?
Training more healthcare workers in Primary Health Care faces several challenges. Hospital and specialist roles are often perceived as more prestigious, making them more attractive to graduates compared with careers in Primary Health Care. This perception is reinforced by inadequate financial and professional incentives for Primary Health Care roles: salaries are lower, there are limited opportunities for advancement, and limited continuing education.
Moreover, despite national strategies emphasising the importance of Primary Health Care, there is frequently a disconnect between policy and practice due to bureaucratic hurdles, insufficient funding, or a lack of political will. This leads to significant policy and implementation gaps. Funding for health science education is currently mainly situated in large teaching hospitals that provide specialists and sub-specialist health care. There is inadequate funding to support health sciences trainees in the district health system. Even though there is a willingness to accommodate these students, the lack of dedicated funding creates tensions that are exacerbated by the austerity.
In addition, although an increasing number of graduates are being produced, their absorption within the health system is considered “unaffordable” within the current context of austerity in health funding.
What should training for Primary Health Care look like?
From all the above it’s clear that in order to reach our Primary Health Care and Universal Health Coverage goals, drastic measures are needed. One aspect that needs to be strengthened is ensuring that training, while being Primary Health Care focused, also reinforces the skills needed for integrated interdisciplinary clinical care.
Studies have shown that medical graduates receive limited exposure to Primary Health Care training and settings in their undergraduate years. This is despite the fact that these skills and knowledge prove to be useful not only to their overall clinical abilities, but to key competencies around community engagement and team-based care. In fact the Cuban-trained students, whose training focuses largely on primary care, display greater competency in critical Primary Health Care skills than South African-trained students.
Read more: For universal healthcare and NHI to succeed, SA needs effective health promotion programmes and institutions
Even when there is some exposure to Primary Health Care, the training is not done in an interdisciplinary way. Trainees are not taught to work collaboratively in diverse teams that are able to provide a comprehensive package of care — the focus is still largely on curative care with limited focus on health promotion and behaviour change communication, rehabilitation and palliation. This is seen specifically in the private sector, where Primary Health Care is often delivered by solo general practitioners (GPs), lacking the interdisciplinary, team-based approach crucial for effective and comprehensive care.
If the NHI aims to foster quality team-based care, healthcare workers will need early and continuous training in teamwork, communication, leadership, collaboration, cultural competency and a shared understanding of diverse health professions’ roles and expertise. The current training and service delivery platforms are not designed to facilitate this care model.
In addition to improvements in formal training, workplace-based supervision, support and clinical mentoring is required to enhance competencies, practical skills and foster a culture of continuous learning. The latter requires creating a supportive environment that encourages acknowledgement of errors without blame, willingness to listen and learn from patient complaints and patient safety incidents, and a commitment to continuous quality improvement.
How should we pay for genuine Primary Health Care?
The NHI proposes a capitation-based model. However this presents its own set of challenges. Capitation involves paying a fixed amount per patient per period, regardless of the number or nature of services provided. This is designed to incentivise prevention, health promotion, and the efficient use of resources, because providers are rewarded for keeping patients healthy rather than for the volume of care delivered. In theory, this aligns with the goals of Primary Health Care, which emphasises prevention, early detection, and continuous, integrated care.
In practice, though, capitation can lead to unintended negative consequences if not carefully implemented. For example, one concern is that providers may underdeliver care to stay within budget, particularly if payment levels are set too low or if there is inadequate oversight and regulation. This is a particular risk when healthcare infrastructure is already strained and where there is insufficient investment in ensuring the quality of services. Additionally, in South Africa there is a significant variation in the capacity of providers, particularly between urban and rural areas.
Read more in Daily Maverick: What would it take to turn NHI into universal healthcare?
Without appropriate mechanisms to take account of these disparities, capitation could exacerbate existing inequities, leaving patients in hardly reached areas with even fewer resources and a further risk of being underserved. It must be highlighted that providers in both the public and the private sector do not function in an efficient way. In the private sector, inefficiency results from the predominant fee-for-service model, which encourages overservicing. On the other hand, in the public sector the salary and budget approach does not incentivise providers to think about the monetary implications of the care they deliver.
In neither case are the outcomes of patient care taken into account. To mitigate these risks, the NHI will need to once again ensure that healthcare workers are capacitated to function effectively in this shared risk model. Additionally, mechanisms for provider support, quality assurance and accountability will be essential. This might include regular feedback and provider engagement around outcomes, patient satisfaction surveys, and a system of penalties or rewards based on performance indicators.
However, in order to prevent undue risk to providers, specifically those in under-resourced areas and facilities, a blended payment model may also assist: such an approach could include salaries (to protect individual provider incomes) along with capitation for service provision and pay-for-performance measures to incentivise key interventions e.g. screening. Furthermore, increased and well allocated funding for infrastructure, particularly to historically under-resourced Primary Health Care facilities, will be vital to ensuring that all providers have the resources available to achieve Primary Health Care aims.
How will integrated care be achieved across the health sector?
The processes of integration of public and private sectors in Primary Health Care delivery is of utmost importance. The private sector in South Africa plays a significant role in healthcare provision, yet it remains largely separate from public services. The NHI proposes integrating these sectors through establishing Contracting Units for Primary Care.
According to the Board of Healthcare Funders (BHF) 2022 report, South Africa has approximately 14,812 family practitioners. This represents a significant workforce for Primary Health Care, and the injection of these practitioners into the NHI primary care model will go a long way in improving access to services. It would also be an opportunity to harness the resources and expertise of private healthcare facilities to expand access to care.
But two challenges in particular arise:
- The first is that the Primary Health Care workforce requires the augmentation of a wider range of healthcare workers, from nurses to allied health workers, and recruitment of GPs alone will not address those service gaps. Additionally, GPs are a relatively more expensive resource, especially when the range of Primary Health Care services that could be task-shifted are taken into consideration. Once again efforts at integrating GPs in a manner that addresses task shifting and improves efficiency will be necessary.
- The second challenge will occur in shifting from fee-for-service to capitation. This will require not only financial adjustments, but also cultural changes within private practice. Many private providers are accustomed to high reimbursement rates, and the lower payments under capitation may make them reluctant to participate in the NHI. Details of how the capitation fee gets divided between a multi disciplinary team for the various services rendered still have to be worked out. However, lower payment fees under capitation should not be construed to necessarily equate to poorer quality health care. The Health Market Inquiry has found that the private healthcare sector in South Africa is characterised by unnecessary high costs, market concentration, and a lack of competition, leading to inefficiencies and limited access to affordable care. Ensuring that private providers buy into the NHI system will require negotiations on capitation rates and the potential to introduce blended payment models. Transparent and consistent engagement with stakeholders such as clinical societies and provider representatives will move the needle from resistance to co-creation and, hopefully, buy-in.
Furthermore, relationships between the private providers and the public sector providers need to be strengthened. Effective local mechanisms must be developed that enable the strengthening of relationships across both sectors, sharing of good practice and harnessing collective efforts towards shared health outcomes of local communities. This would ensure continuity of care and allow for more coordinated management of chronic diseases, which are a growing burden on the healthcare system.
Where do communities fit in?
Research shows that social accountability improves health system responsiveness and health outcomes. Social accountability is defined as “an approach towards building accountability that relies on civic engagement, i.e. in which it is ordinary citizens and/or civil society organisations that participate directly or indirectly in exacting accountability”.
Community participation and social accountability are not only central to Primary Health Care but constitutional and legal commitments. Legislative provision has been made for structures such as clinic committees, hospital boards and district health councils. But in practice these statutory structures have been established with difficulty and function to varying degrees — more often than not sub-optimally. Weak governance, limited community awareness of their roles, and inconsistent government support have contributed to this.
On the other hand, there are promising models that demonstrate the potential of effective community engagement. Initiatives like Operation Sukuma Sakhe in KwaZulu-Natal, the Ritshidze project focused on approximately 400 Primary Health Care clinics, and the Bulungula Incubator in the Eastern Cape showcase how localised, community-led accountability efforts can lead to tangible improvements in healthcare delivery and service responsiveness. These initiatives, with their focus on high-risk populations and rural development, offer valuable lessons on how to build and sustain social accountability mechanisms.
Communities are rich in assets, including local leaders, knowledge-bearers, and networks of community organisations focused on various aspects of social life such as civil society, youth, women, sports, and religion. These assets should be harnessed to co-create solutions to health service challenges. Additionally, building social accountability must involve empowering frontline facility managers and healthcare workers, especially community health workers. These workers must be equipped with the confidence, skills, and institutional support to constructively engage with communities, listen to their feedback, and respond to local needs and priorities. Upskilling and creating mechanisms for these engagements will foster trust and strengthen the health system’s responsiveness to its users.
https://www.youtube.com/watch?v=uVSgxgFoys4
Beyond statutory structures, fostering an enabling environment for grassroots civil society organisations is critical. These organisations often act as the first line of accountability, raising awareness and educating communities about their rights, advocating for improved services, and monitoring health system performance. The government and civil society must collaborate to ensure that accountability mechanisms are not seen as punitive or oppositional, but rather as tools for improving service delivery and community wellbeing.
As we move forward with an NHI system, the role of social accountability will be crucial and will require robust feedback loops between service users and providers to ensure that it responds to the actual needs of the population. Communities must have an active voice in this! Moreover, formal structures should be coupled with more informal, adaptive approaches to social accountability that allow for real-time problem solving and responsiveness to emerging challenges.
In this context, the healthcare system must rapidly develop a culture of accountability at all levels. This includes building transparent systems for reporting and addressing patient complaints, integrating community feedback into quality improvement, and ensuring that healthcare workers are supported to engage with and be accountable to their communities. Such a shift will help restore public trust in the healthcare system and drive better health outcomes.
Read more: Consensus, common purpose and unified commitment to South Africa's healthcare reform urgently needed
Finally, at the heart of achieving an effective Primary Health Care system under the NHI is the need for a shift in mindset. Policymakers, healthcare professionals, and the public need to collectively reframe how they view health and healthcare. Instead of focusing primarily on treatment and cure, there needs to be a greater emphasis on health promotion and prevention, early intervention, and maintaining health within the community. This is the essence of Primary Health Care, and it is also the key to ensuring that South Africa’s health system can deliver equitable, accessible, and sustainable care for all.
In conclusion, we have shown in this article that while Primary Health Care already accounts for approximately 90% of patient contact with the health system, significant gaps remain in both policy and implementation. Addressing the human resource challenges, realigning training and education to be Primary Health Care-centric, introducing a strategic purchasing model that supports high-quality care, fostering greater collaboration between the public and private sectors while enhancing community involvement are critical steps toward realising the full potential of Primary Health Care.
Some of these tenets are already contained within the NHI Act and the National Health Act. More clarity will emerge with the imminent publication of the NHI regulations. However, the shape and form of these initiatives must be moulded from the collective wisdom of many stakeholders, the lived experience of practitioners and communities, and innovative models and ways of thinking. Strengthening the Primary Health Care platform to be more responsive to the population’s health needs and priorities cannot be postponed any longer. The success of NHI will ultimately depend on how effectively and quickly these elements are incorporated into the broader health system reform, ensuring that all people in South Africa, regardless of where they live or their socioeconomic status, have access to the healthcare they need. DM
This is the fourth of a series of articles that suggest practical programmes and approaches that could be the basis for a reinvigorated programme for health reform, focusing on what can be done now if there is will in the health sector and beyond to reprioritise public health.
The authors write in their personal capacity. Atiya Mosam is a public health medicine specialist and an independent consultant and founder of Mayibuye Health, which specialises in health systems strengthening, PHC and health financing. Sue Goldstein is a public health medicine specialist, managing Director at the SAMRC Centre for Health Economics and Decision Science-Priceless SA and a professor at the Wits School of Public Health. Krish Vallabhjee is a public health medicine specialist, an adjunct associate professor at the Health Systems and Policy Division, School of Public Health, University of the Cape Town and technical adviser to Clinton Health Access Initiative. Tracey Naledi is a public health medicine specialist, an associate professor of public health medicine, deputy dean: Social Accountability and Health Systems, Faculty of Health Sciences, UCT and chairperson of Tekano, Atlantic Fellows for Health Equity in South Africa. Mark Heywood is an adjunct professor at the Nelson Mandela School of Public Governance at UCT and an independent health and human rights activist.