When the South African President announced the initial lockdown at the start of the coronavirus disease 2019 (COVID-19) pandemic in South Africa (SA), he stated that ‘temporary shelters that meet the necessary hygiene standards will be identified for homeless people’.¹ However, there was no clear strategic plan, and it was implied that provincial and local governments would be responsible for the implementation of the plan. With the historical failure in the City of Tshwane (CoT) to address homelessness, the lack of dedicated budgets for implementing the Street Homelessness policy for the CoT,² led initially to sporadic responses by the local government, which became more coordinated during the weeks that followed.^3,4 This failure is detailed, with the extent of the issue, in two reports– Pathways out of Homelessness: Research Report 2015⁵ and Homelessness and COVID-19 in the CoT: Research report 2021.³ The 2015 report resulted from a transdisciplinary research project with over 40 researchers from various disciplines and universities, as well as practitioners and people with lived experiences of being homeless. It found that there were 6244 homeless persons in the CoT, which led to the 2019 CoT Street Homelessness policy. The 2021 report details the efforts towards addressing homelessness during COVID-19 lockdown in the CoT (April–August 2020). It describes the collaboration between more than 24 organisations and institutions to develop 1800 new bed spaces, ensuring access to healthcare for the homeless. It also highlights the use of technology and effective communication.

The Department of Family Medicine (DFM) at University of Pretoria has had a strong presence in communities around the CoT for a few years already, working closely with the district healthcare services. One of its notable achievements is the formation of the Community Oriented Primary Care Research Unit (COPC RU),⁶ which was established in 2016 to create a service learning research platform. The Unit has established university-run clinics in Daspoort as well as in the informal settlements of Melusi, Zamazama (west of Pretoria) and Woodlane (east of Pretoria). These clinics aspire to offer services to the whole population that (1) are coordinated for effective, equitable quality healthcare delivery; (2) are patient-centred and delivered from the home, street, clinic or general practice to the hospital and back again; and (3) include an academic platform to support an apprenticeship model of education, workplace learning, research, monitoring and evaluation – supported by modern technology. It was against this background that the Gauteng Department of Health (GDH) and the CoT approached the DFM to assist with health interventions during the COVID-19 lockdown. It was an opportune time for the DFM to become more innovative, as Tshwane District Hospital had been converted to a COVID-19 hospital and the registrars needed alternative placement for their professional growth. The DFM rolled out health interventions to include homeless shelters and managed the coordination of healthcare for residents, with support from the GDH and other partners.

The clinical specialty of Family Medicine is patient-centred, evidence based, family-focused, and problem-oriented.⁷ It emphasises the relationship with the patient and seeing the person as a whole, in the context of their family (next of kin or relevant others) and their wider community.⁸ The location of family physicians (FPs) in the African continent varies from tertiary hospitals (Nigeria) to health districts as part of district clinical specialist teams, district hospitals or in primary care (SA).⁹ We interpret these settings as care in the home, clinic or hospital and includes homeless people where the home is the street or a shelter.¹⁰

This short report focuses on the role played by FPs (and family medicine registrars) in providing healthcare for the sheltered homeless people during the first 6 months (April 2020 to September 2020) of the COVID-19 lockdown¹¹ in the CoT. It examines how FPs responded with agility to the unprecedented chaotic situation. Furthermore, it describes the health interventions implemented by the DFM and how the roles of the FPs extended to communication, collaboration and innovation.¹² It also highlights FPs’ roles in capacity building, community-based care, person-centred care, continuity of care, linkage to care and multi-disciplinary teams. In providing clinical care, FPs also worked with clinical associates who are part of the Community Oriented Substance Use Programme (COSUP).¹³

The relevance of this report is that it examines the roles that can be played by FPs during public health crises, and highlights the importance of their role within community-based multidisciplinary teams.

The interventions are located geographically in the CoT, Gauteng, SA, which is within the health district of Tshwane. The timeline of the report is the first 6 months of the COVID-19 lockdown. Family physician-led multidisciplinary teams rolled out healthcare interventions in both permanent and temporary shelters (totalling 25) managed by various stakeholders, and extended these interventions to other settings, such as primary health care (PHC) clinics and buildings, used by the homeless.

Table 1 shows the thematic or operational areas in which FPs played a role in providing healthcare services for sheltered homeless populations during the 2020 COVID-19 lockdown in the Tshwane district.

The DFM, through the COPC RU’s programmes such as COSUP,¹⁴ has been providing healthcare services to homeless people on the street for 5 years. The establishment of new shelters and the influx of additional homeless people to the existing shelters were an opportunity to provide integrated healthcare to homeless populations, rather than expecting that they would come to healthcare facilities.

The initiative provided integrated healthcare for people in their context. Although the care was provided in crowded, noisy settings, it was an appropriate service for the residents to get a comprehensive and integrated care, tailored to their identified needs. Family physicians moved beyond their comfort zones and learnt a number of skills which were not usual for their workplace⁴ (Table 1). This disruption provided an opportunity in strengthening the district healthcare services that were stretched to the limit at that time, both by the high numbers of sick people needing care simultaneously and by an unusually high number of ‘captive’ populations needing care.

The high ‘captive’ population situation was a result of street people, normally lost to the system, gathering at the many shelters. An opportunity arose to collect data and gain deeper understanding of the health needs of homeless people. An unprecedented number of substance users were initiated on opioid substitution therapy.¹⁸ Moreover, others got weaned off harmful substance use, either because of not finding suitable alternatives to their usual substances or embracing lifestyle changes through other services offered.

The homeless were screened and assessed for various conditions, and initiated or reinitiated on treatment, a move that increased access to healthcare in the district for that group. Technology utilisation improved in the district health system, as FPs interacted mainly via Zoom, telemedicine and Vula Mobile application¹⁶ to exchange information, and had to learn fast how to compile data and use data collection tools, which was previously unfamiliar.

The impact of FPs’ activities in providing healthcare services to the sheltered homeless populations during the COVID-19 lockdown in Tshwane district can be considered according to six previously defined roles: care provider, consultant, clinical trainer, leader of clinical governance, champion of community-orientated primary care and capacity builder.¹⁹ Table 1 lists the operational areas in which FPs played a leading role and made a significant impact in healthcare services. It demonstrates how FPs went beyond their roles expected in SA’s health system. The unique contributions of FPs to the teams were the following: initiation of medication for acute and chronic diseases identified; telemedicine consultations; care coordination across shelters and facilities; development of district-wide standard clinical approaches to contain COVID-19; screening for diseases and harmful substance use, as well as screening, swabbing and linkage to care for COVID-19; collection of clinical data and training of data capturers for appropriate data collection and cleaning; using the Vula application for specialist referrals; undertaking a quality improvement project, as well as training shelter managers on COVID-19 protocols.

Table 2 illustrates the impact made by one team of FPs providing services in a particular shelter over three of the 6-month period. By caring for the homeless people outside of the primary care facilities, they also reduced the workload of these facilities. It shows the numbers attended to daily through the different alert levels. It also illustrates early detection of diseases, initiation and continuity of clinical care and linkage to health services. The pandemic peaked during alert level 3 lockdown,¹¹ which started in June, whilst the DFM continued service delivery. As numbers declined from July, some residents voluntarily left the shelters whilst those remaining were gradually transferred to permanent shelters.

As lead clinicians in primary care, FPs can adapt to emergency situations and play a role beyond what is normally expected of them within district healthcare services in South Africa. The disruption resulting from the first 6 months of the COVID-19 lockdown in the country presented an opportunity for the FPs to go beyond their normal clinical roles by immersing themselves into additional activities, including data management, research and effective utilisation of technology. Family physicians also played an extended role in capacity building as a result of this initiative, which included training on the wearing of masks, proper hand washing, and training on COVID-19 swabbing for nurses and clinical associates. Begun and Jiang¹² suggest that an appropriate response during the COVID-19 pandemic is to ‘emphasise communication, collaboration, and innovation’, as well as building connections, at great speed. The responses from FPs during the COVID-19 pandemic, as highlighted in this report, were therefore appropriate.