A total of 16 interviews were conducted by 6 different interviewers in the following countries: South Africa, Lesotho, Botswana, Swaziland, Kenya, Uganda, Rwanda and Ghana. After 16 interviews were completed it was decided by the research team that there was sufficient data for analysis. Suitable respondents in the other countries in the Primafamed network were not able to be identified and interviewed within the time period allocated for data collection.
Contextual issues: External Collective theme
All respondents were very aware of the constraints of their contexts and readily volunteered information on this theme. A common and often repeated statement concerned the general lack of resources to cope with the burden of illness in Africa. This related to the shortage of qualified staff, and lack of equipment as well as medication, and the resultant work overload of the few who do fill the posts. Under the best circumstances it leads to an innovative and adaptable approach of making the most out of what few resources there are. But most of the time it just leads to frustration and burnout, and contributes to the rapid turnover of staff.
'We are short staffed on the nurses' side and with the doctors... we don't have enough time with each patient because of the pressure of have to push the queue'.
'You have 40 to 60 patients to see per day'
The rural context of many of the respondents had both negative and positive aspects-although there were many frustrations, some respondents found satisfaction from working in under-served areas:
'working in a small rural place I get a lot of satisfaction with working with rural people who need medical attention'.
Traditional health beliefs formed part of the context. There was recognition that many patients used traditional healing before consulting the generalist, although attitudes varied from openness and acceptance to rejection and hostility.
'Most of them resort to traditional treatment. Some consult the churches for prayer; most people believe that every disease in Africa is given by a close relative so they believe in the spiritualist first. Many of them come in critical condition'.
In addition to resource constraints, there were also health system failures that created significant challenges:
'When mistakes occur, it is a system failure not the level of competency'.
Referral of patients to higher levels of care was a huge challenge, and required practitioners to constantly upgrade their skills, as they were often forced to deal with clinical problems beyond their comfort zones.
'One is forced to extend one's capacity continuously'.
Nevertheless, most asserted that generalists manage 90% of patients seen and only refer a minority.
With regard to career choice, it was interesting to note that most respondents were generalists by default and not by choice and would have preferred to specialize if they had had the opportunity.
'It's not a choice for me to be a generalist; I would have liked to do something more than being a generalist'.
The absence of a career path for a generalist clinician, and the lack of benefits in addition to the heavy workload, made this an unattractive career choice for clinicians in Africa.
Internal Individual theme
The internal individual theme related to personal issues of motivation and principles, by which practitioners order their lives and do their work. Four sub-themes arose from the data in the interviews: motivation, attributes, national responsibility, and continuing professional development.
Motivation as a generalist was easily and well described. A clearly expressed drive was to make a difference, despite the context. It was felt important that they be 'making a difference to individual lives', and one described his work as 'a passion for assisting people'.
Individual sources of motivation were described in different ways, such as:
'from childhood I wanted to be a doctor. For me it was really important to help people. I can see it as I'm helping people'.
'I'm a Christian guy so religion plays a role there'
'You operate [on] a patient with a serious problem, and then you see him walking. You feel happy.'
Respondents described the various attributes required of them as generalists, mostly regarding relationships with patients and colleagues, such as commitment, respect, empathy, caring, compassion, integrity and trust, but also other qualities:
'I try to treat everybody with respect... it's about being a people's person'.
'It's flexibility: it's the ability to multitask and improvise and to provide leadership.'
'You should be working as a warrior,...get tough though there are challenges, but we should accept......'
The important attributes were also described in terms of technical and organizational issues, such as thoroughness, knowing one's limits, having a systematic approach, being flexible and able to improvise and innovate.
'You have to learn to listen to the patient and to take proper history from the patient... physical examination... investigation... differential diagnosis... actual diagnosis'.
'You work as an individual but I also realized that you need some structure and assistance to get things done.'
There was also a sense of social and national responsibility that was expressed explicitly by some:
'I feel that I have a role to play towards the development of the country, the well being of the people, this is why I still remain in government...'.
'I need to be part of a group of people that are responsible for finding solutions to the good health of all Rwandans'.
There were also important personal connections to their context:
'Then the environment, this is where I got married. So all these people I treated them as my what, my relatives'.
'I grew up in a rural setting and because of that I know life in the rural areas can be meaningful. I feel I should have a contribution to the locals..'
One respondent proposed rewards and incentives for staff, including verbal positive feedback, certificates, trophies and relationships with the system.
'I need to be motivated externally by my bosses in the province. But internally mine is actually my work.'
Some were motivated by the challenges themselves:
'But what motivates me especially in those rural facilities is the challenge of delivering the health services where access is a problem'.
Ongoing learning was seen as driven by need, and this was seen to attract young doctors:
'Continuous training is essential', and 'if we do not train, if we do not get more skills then you cannot be able to give the required quality of care to our patients'.
Professional development was seen as self-directed: 'its all up to you'. Learning was usually in the mode of supervised practice with colleagues, but there were also formal courses and lectures. Experienced medical officers requested recognition of their experience.
External Individual theme
This theme relates to the visible roles, activities and behaviours of the respondents as generalist clinicians in public service in African countries. Relationships with their patients were seen as paramount, and they therefore placed high importance on relational skills. They were also quite aware of the social, economic, psychological and cultural issues that impact on a patient's illness:
'Most of our health problems are lifestyle diseases anyway. So if it's a lifestyle disease then these are socio-cultural issues.'
'Some patients they bring such pains because, well they are not actually bringing the pain but they are bringing the social burden they have in their lives and everything.'
'I do not manage diseases, I manage the patient... Sometimes... the problem the patient does not tell you... you listen and know the problems behind it.'
This understanding of the complex determinants of illness led to an appreciation of the need to listen carefully to patients:
'The principle is to get the history from the patient...in an open way so that the patient feels free...the patient must not feel that he has to tell you what you want to hear.'
Even beyond this, some spoke of the need for empathy with patients:
'you must stand in the boots of that person and you must, you must tailor what you do to that person according to that.'
Other equally important relational issues were mentioned: the need for trust, respect, and honesty with patients, the importance of confidentiality, and the value of a continuing relationship, especially with those with chronic diseases.
Respondents accepted the need to do hospital ward work, and even major surgical procedures. The lists of procedures varied from place to place. For some it was smaller out-patient procedures:
'circumcisions... minor surgery: small cases... small abscesses, cysts, incisions'
While for others it involved major surgery:
'appendicectomy, prostatectomy, laparotomy... c/sections, and oophorectomy.'
Another role that most respondents found themselves involved with is administration and management. Sometimes it was simply organizing and attending meetings for purposes such as continuous professional development, audits, or mortality reviews. Often the tasks went beyond this, and involved conflict management among staff members, problem solving of clinical issues, and 'thinking strategically' to 'bridge the gap between planning at the district level and translation into reality at the coalface'.
Some were in more defined leadership roles:
'It's like a sort of puppet master: you pull strings and make sure that everybody is in the right place at the right time.'
Not surprisingly, these additional management duties can lead to tension:
'The balance between clinical work and managerial work is difficult.'
Most respondents were also involved with teaching, especially for medical students, interns, and junior doctors, but also for nurses and community health workers. Most of this was done on the job, by mentoring, role-modeling, and clinical teaching, although a few gave lectures as well.
'Students .... participate, they become quite functional. So they just join the team and ..... the training they get is not that formal.'
'So I see my role now basically at the present moment is to, to help those, to teach them...to help themselves so after two, three, four months they will be sort of independent '
These were tasks that were accepted without the tension noted with management. Yet there was also a recognition of the need for these generalist 'teachers' to themselves be taught beyond medical school, either 'by extending the duration of the medical school even to cover 8 to 10 years', or 'post-medical school one year in every discipline...'
Involvement in community health activities, however, revealed a different pattern. Most generalists affirmed in theory that community health was important and a few had been involved with outreach clinics or education to community groups. However, few, if any, of our respondents were actively involved with community health:
'there should be that link between the health workers and the community'
'We sit here, we don't go to the community, we only sit down and see patients as they come here.'
Finally, many respondents affirmed the importance of teamwork, both for hospital management and for district health management.
'What's important is to build a very good teamwork around your department, make sure every work goes on with minimal supervision.'
Some generalists seemed successful in encouraging and shepherding effective teams at their places of work. However, many admitted that there were major barriers to developing effective teams.
'The health care system... would be excellent, but the problem is that apparently there is no team work...'.
A particularly poignant admission was the difficulty doctors and nurses sometimes have working together. Nurses may resent doing things 'for the doctor', and one doctor felt:
'it's like you are asking them a favour to look after a patient.'
This could lead to anger toward nurses, which one doctor admitted was destructive of teamwork.