Background: Experiences from infectious outbreaks globally, such as Ebola and severe acute respiratory syndrome (SARS), highlight the challenges of government to maintain essential healthcare services, guarantee healthcare access and at the same time shift resources to contain and mitigate the crisis. The declaration of the State of Disaster in South Africa due to the COVID 19 pandemic (on the 15th of March) and the subsequent imposition of a total national lockdown on all usual activities were anticipated to have both direct and indirect negative consequences on healthcare utilisation including reproductive healthcare services. Objective: The objective of this study is to describe the effect of the COVID-19 pandemic on family planning and termination of pregnancy services utilisation immediately following the lockdown in Gauteng Province. Methods: We analysed the administrative data on clinical services utilisation during the previous two years, including five weeks following the enforcement of the lockdown in South Africa, from the District Health Information System database over the period 1 April 2018-30 April 2020. Results: Primary healthcare utilisation headcounts across the province declined by nearly 500,000 visits following the lockdown period. Family planning utilisation patterns which are demand-driven declined during the two months preceding the COVID-19 pandemic and further declined during the lockdown. Switching contraceptive methods to those with less effectiveness were noted as a trend over the previous two years. Year on year comparisons from April 2018 to April 2020 indicated a consistent decline in the use of injectable methods and increased use of oral contraceptive pills. Conclusion: This review highlights the importance of monitoring the utilisation of routine healthcare services during the outbreak situations to ensure that service provision is not compromised. Women of reproductive age must be able to exercise their reproductive choices to prevent unintended pregnancies and to reduce their risk of mortality as a result of diminished access to reproductive healthcare services.

Background: Health policy-makers in Africa are looking for local solutions to strengthen primary care teams. A South African national position paper (2015) described six aspirational roles of family physicians (FPs) working within the district health system. However, the actual contributions of FPs are unclear at present, and evidence is required as to how this cadre may be able to strengthen health systems. Methods: Using semi-structured interviews, this study sought to obtain the views of South African district health managers regarding the impact made by FPs within their districts on health system performance, clinical processes and health outcomes. Results: A number of benefits of FPs to the health system in South Africa were confirmed, including: their ability to enhance the functionality of the local health system by increasing access to a more comprehensive and coordinated health service, and by improving clinical services delivered through clinical care, capacitating the local health team and facilitating clinical governance activities. Conclusions: District managers confirmed the importance of all six roles of the FP and expressed both direct and indirect ways in which FPs contribute to strengthening health systems' performance and clinical outcomes. FPs were seen as important clinical leaders within the district healthcare team. Managers recognised the need to support newly appointed FPs to clarify their roles within the healthcare team and to mature across all their roles. This study supports the employment of FPs at scale within the South African district health system according to the national position paper on family medicine.

BackgroundEvidence from first world contexts support the notion that strong primary health care teams contain family physicians (FPs). African leaders are looking for evidence from their own context. The roles and scope of practice of FPs are also contextually defined. The South African family medicine discipline has agreed on six roles. These roles were incorporated into a family physician impact assessment tool, previously validated in the Western Cape Province.MethodsA cross-sectional study design was used to assess the perceived impact of family physicians across seven South African provinces. All FPs working in the district health system (DHS) of these seven provinces were invited to participate. Sixteen respondents (including the FP) per enrolled FP were asked to complete the validated 360-degree assessment tool.ResultsA total number of 52 FPs enrolled for the survey (a response rate of 56.5%) with a total number of 542 respondents. The mean number of respondents per FP was 10.4 (SD = 3.9). The perceived impact made by FPs was high for five of the six roles. Co-workers rated their FP’s impact across all six roles as higher, compared to the other doctors at the same facility. The perceived beneficial impact was experienced equally across the whole study setting, with no significant differences when comparing location (rural vs. metropolitan), facility type or training model (graduation before and ≥ 2011).ConclusionsThe findings support the need to increase the deployment of family physicians in the DHS and to increase the number being trained as per the national position paper.Electronic supplementary materialThe online version of this article (10.1186/s12875-018-0710-0) contains supplementary material, which is available to authorized users.

Wars must be won if our country. .. is to be protected from unthinkable outcomes, as the events on September 11th most recently illustrated.. .. This best protection unequivocally requires armed forces having military physicians committed to doing what is required to secure victory.. .. As opposed to needing neutral physicians, we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs of the mission. 1 Counterpoint: We believe the role of the "physician-soldier" to be an inherent moral impossibility because the military physician, in an environment of military control, is faced with the difficult problems of mixed agency that include obligations to the "fighting strength" and. .. "national security." 2 These two quotes typify the competing worldviews brought to bear on the ethical and human rights obligations of health professionals in the armed forces. Attention has focused increasingly on the role of health professionals in abuses of detainees in military custody 3 following revelations of gross human rights violations at the Abu Ghraib detention center in Iraq. 4 It is important to note, however, that detainee abuse illustrates but one example, albeit particularly egregious, of a deeper problem of dual loyalty (alternatively called mixed agency) 5 in the military. 6 As health personnel are torn between duties to heal on the one hand and to support military objectives on the other, these tensions result in inevitable ethical and human rights consequences for both soldiers and civilians. Historically, ethical obligations of health professionals have privileged the need for loyalty to patients. In the modern world, however, health professionals are frequently placed in settings where they are asked to weigh their devotion to patients against service to the objectives of government or other This paper is based on the Dual Loyalty Project (1998-2000), which was funded by the Greenwall Foundation to develop guidelines that protect the human rights of patients in situations where health professionals face dual loyalty conflicts. The intellectual contributions of the International Dual Loyalty Working Group, as well as the assistance of Ms. Kathy Mallinson and Dr. Joanne Stevens in preparing this manuscript are gratefully acknowledged.