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Background: Strengthening primary health care (PHC) is a priority for all effective health systems, and family physicians are seen as a key member of the PHC team. Zimbabwe has joined a number of African countries that are seriously considering the introduction of postgraduate family medicine training. Implementation of training, however, has not yet happened. Aim: To explore the views of key stakeholders on the introduction of postgraduate family medicine training. Setting: Key academic, governmental and professional stakeholders in Zimbabwean health and higher education systems. Method: Twelve semi-structured interviews were conducted with purposively selected key stakeholders. Data were recorded, transcribed and analysed using the framework method. Results: Anticipated benefits: More effective functioning of PHC and district health services with reduced referrals, improved access to more comprehensive services and improved clinical outcomes. Opportunities: International trend towards family medicine training, government support, availability of a small group of local trainers, need to revise PHC policy. Anticipated barriers: Family medicine is unattractive as a career choice because it is largely unknown to newly qualified doctors and may not be recognised in private sector. There is concern that advocacy is mainly coming from the private sector. Threats: Economic conditions, poor remuneration, lack of funding for resources and new initiatives, resistance from other specialists in private sector. Conclusion: Stakeholders anticipated significant benefits from the introduction of family medicine training and identified a number of opportunities that support this, but also recognised the existence of major barriers and threats to successful implementation.
This was a phenomenological qualitative study that used semi-structured interviews to explore the views of key stakeholders in Zimbabwe. The Ministry of Health’s (MoH) mission is to provide, administer, coordinate, promote and advocate for the provision of equitable, appropriate, accessible, affordable and acceptable quality health services and care to Zimbabweans, while maximising the use of available resources, in line with the PHC approach.13 Post independence, the Government of Zimbabwe (GoZ) invested heavily in PHC through, for example, the development of community health workers, PHC infrastructure and training of competent health professionals.14 As a result, Zimbabwe recorded good progress in family planning, maternal and child health in the period 1980–1995. Thereafter, economic challenges, loss of skills and the HIV pandemic affected the health service delivery system and progress could not be maintained. Women and children, being more vulnerable, have been the most affected by the deterioration of some aspects of the health system.14 At the time of the study, CPCPZ was working closely with Stellenbosch University in South Africa and was partnered with the University of Zimbabwe’s College of Health Sciences (UZCHS), with the full support of the GoZ, to introduce family medicine training in Zimbabwe. CPCPZ are a professional body for primary care physicians and the majority of its members are in private practice. This partnership saw a cohort of FPs being trained at Stellenbosch University and by 2017 four had graduated. The Medical and Dental Practitioners Council of Zimbabwe (MDPCZ) opened a new register for family medicine and these four were successfully registered, marking the entry of family medicine in Zimbabwe. All of the above organisations are considered key stakeholders in the provision of PHC and introduction of family medicine in Zimbabwe. In addition, the central hospitals, Health Services Board (HSB), DHS and Zimbabwe Medical Association (ZiMA) are key stakeholders. The researcher undertook this study as part of the Master’s of Medicine in Family Medicine at Stellenbosch University. He is amongst the Zimbabwean pioneers to undertake studies in family medicine at Stellenbosch University. At the time of the study, he was part of the lobbying and advocacy group for training in Zimbabwe. Criterion-based purposeful sampling was used to identify eight interviewees, one from each of the stakeholder organisations (MoH, CPCPZ, UZCHS, MDPCZ, central hospitals, HSB, DHS and ZiMA). This entailed purposively selecting senior individuals in each organisation who were likely to be ‘information-rich’ and able to engage with the aim of the study. Only individuals who had been in their post for the last five years were eligible for selection. Those who were engaged in postgraduate family medicine training or who had such qualifications were excluded. After the first eight interviews, a preliminary analysis suggested there was need to perform additional interviews to explore emerging themes in more depth or to clarify issues raised. Snowball sampling was then used to identify four additional interviewees that were likely to shed more light on the emerging themes or explain certain concepts in more detail. The interview guide (see Appendix 1) reflected the aim of the study and ensured that the participants’ understanding of family medicine, ideas about the contribution of family medicine to the health system and views on training were explored. Open-ended exploratory questions were used with reflective listening, summaries and clarifications where needed. The first three tapes were reviewed by the researcher and supervisor to ensure that the guide was appropriately constructed and that the researcher possessed necessary interviewing skills. The opening question was ‘Please tell me what you know about family medicine, its benefits and any possible concerns that you may have’. Interviews were conducted by the principal researcher from June 2015 to April 2016. Nine interviews were performed by the researcher in the interviewees’ offices, three by cell phone, and each interview lasted between 30 and 60 min. Eleven interviews were performed in English and one was in Shona. All interviews were transcribed verbatim by a research assistant and these were then cross-checked against the audiotapes by the researcher. The interview material in Shona was translated into English. ATLAS-ti software was used to assist with the analysis of the data using the framework method. The framework method involved the following steps: familiarisation with the raw data, identifying an index of all the codes and categories to be used, applying the index to all the raw data by annotating all the transcripts with the codes, charting all the data from the codes in one category into a single document and interpreting themes from these charts in terms of the range and strength of opinions, as well as any associations or relationships between themes. Analysis was performed by C.S. under supervision of R.M. who particularly checked the coding index and interpretation of data. The Health Research Ethics Committee of Stellenbosch University (S13/04/057) and the Medical Research Council of Zimbabwe (MRCZ/B/597) provided ethical approval.
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