• Improving Care for Marginalized Groups
• Improving Interprofessional Primary Care
• Research on the Impact of CHCs

Community Health Centres (CHCs) in South Africa function within a nurse-driven primary health care system. The few doctors that are placed in CHCs, often in urban centres, struggle to provide leadership in a system dominated by pushing queues. Chiawelo CHC provides comprehensive but very fragmented care to ±300 000 people in a quarter of Soweto, Johannesburg. The "Community Practice" at Chiawelo CHC was set up with doctor leading a multidisciplinary clinical team to comprehensively manage a defined population of 18,000 in the immediate area around the CHC using community-oriented primary care principles. The objective was to see if outcomes could be improved using the community practice model.   

The Chiawelo Community Practice team includes two doctors, a clinical associate/physician assistant, a nurse and 22 community health workers (mostly deployed into defined streets of the community). The team of four clinicians provides comprehensive healthcare to this defined community of 18,124 people. Local community and government stakeholders are engaged, supporting a growing health promotion programme that is embraced by the community. The current team model is not optimal as more nurses are required. However, it has allowed family physicians to experiment with team configurations and a clear population in which to measure health process, outcomes and costs.

The impact has been quite considerable:

•  The utilisation rate at CCP is estimated at 1.3 visits per person per year (pppy) vs. 0.72 visits pppy for Chiawelo CHC overall (based on current headcounts of 18 000 per month and a catchment area of 300 000) improving community access to services.
• Waiting times are low at 25 minutes in CCP vs. 2 hours at the CHC
• CCP costs are estimated at R445 per person per year (pppy) vs. R1054 pppy for the CHC (based on non-hospital PHC expenditure from the DHB 2016/17)
• Satisfaction rates in the community of Ward 11 are very high with over 90% of a random sample of the 18000 population rating CCP at 4-5 stars out of 5
• Broad community engagement is strong with Ward Councillor, Ward Committee and Clinic Committee active champions of CCP.
• Health Promotion activities have resulted in 6 Health Clubs established in the community of Ward 11 involving more than 150 residents in daily exercise. These have expanded to become social assets with strong identities and social action and are the basis for expanding health promotion and social support with cooking classes started and community-based mental health patient support.
• This space is serving as a strong example of the expanded decentralised academic teaching platform for universities (Wits, UJ, UNISA) including multidisciplinary and community-based teaching. Students and teachers find that CCP makes comprehensive PHC and Community-Oriented Primary Care come alive as opposed to just learning from books.
• More than 30% of students and interns visiting CCP find themselves changing their minds about contracting on this basis with National Health Insurance.

This innovation is useful for developing countries. It offers a way to demonstrate family doctor leadership by carving out social laboratories within challenging public health services. Some simple resources added to public services can facilitate the ideal of family and community practice to happen in an otherwise difficult setting.