In my view… September 2019

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Donald Li, WONCA President writes:

Earlier this year, during the World Health Assembly, WONCA agreed to lead a piece of work on the importance of the Primary Care Team to achieve Universal Health Coverage. As family doctors we recognize the importance of working with qualified professional colleagues who provide essential interface and inputs to the delivery of a comprehensive primary care system.

We know that the membership of a primary care team differs from country to country, from town to town and teams even differ within the same neighbourhoods. There is no clear-cut prescription of what constitutes a primary care team. There is no mathematical (or magical) formula which stipulates what the components of an appropriate primary care team are.

Primary care teams are established based on economic viability, resource availability (both human and financial), epidemiological need, location, access and a wide range of other variables. There are many, many, variables as to what makes a ‘good’ primary care team. But one thing we are sure about is that delivering comprehensive person-centred primary care is best achieved by capitalising on the skills and expertise of a range of professionals who work collaboratively. We know that primary care delivered as a series of uncoordinated interventions, often through vertical programmes, does not provide either the continuity or the comprehensiveness of care which is necessary to achieve Universal Health Coverage.

The biggest challenge so far to leading this work is in identifying relevant global organisations with whom WONCA can collaborate to develop models of effective comprehensive primary care delivery. The global organisations we looked for need to reflect the professional groups which make up the broad membership of primary care teams. We have had numerous suggestions of ‘umbrella’ global organisations which represent nurses, occupational therapists, midwives and other clinical and paramedic professions but few which represent those working specifically in a primary care setting.

In this respect family medicine professionals, working as they do in the primary care setting, are very well served: WONCA, as a global organisation representing family doctors across the world, is a unique organisation. The primary care ‘sub sets’ of other professions are less well served.

During a recent WONCA Africa region conference, Professor Shabir Moosa (pictured at right with Donald Li) initiated a movement looking at the different models of primary care delivery across the continent. The initiative gained traction very quickly both within Africa and further afield, importantly among a range of primary care-specific professionals. The importance of working as a primary care team rather than as individual, separate, professionals was a very clear message from the outset. The group, still growing in number, is identified as AfroPHC (see [email protected], webpage and link to join)

Some of the numerically larger primary care professionals (such as community health workers, clinical associates) do not have professional organisations through which to continue professional development, receive additional training, or collaborate with professional colleagues. That remains a challenge. But enthusiastic individuals from these groups have identified themselves and joined the AfroPHC group, and this will encourage professionals from across the continent to join. Many of the individuals from primary care professions who have signed up to AfroPHC are involved in interprofessional education and collaborative practice initiatives (IPECP), in Africa, which bodes well for identifying good models for primary care teams.

There is recognition that the continent of Africa contains some of the most disadvantaged and least developed countries. Health statistics, while variable across the countries of the region, are still frightening. As examples, in 2012 35.4% of total deaths in the region were from HIV/AIDS, lower respiratory disease, diarrhoeal diseases and malaria. In 2013 healthy life expectancy at birth was 51 years for females and 49 years for males. In 2015 under-five mortality per 1000 live births - a key MDG [1] target – had improved significantly to 81 (from 177 in 1990) but Africa still has the highest under-five mortality in the world, ranging downwards from 52 in Eastern Mediterranean region to 11 in Europe in 2015 [2]. With 10% of the world’s population, Africa has 25% of the global burden of disease but only 3% of total global health workforce [3]. These figures make for a major challenge to turn around a history of successive vertical programming and disjointed care into effective, qualified, primary care teams delivering comprehensive primary care.

The well-documented disadvantages in Africa region have spawned numerous innovative approaches to delivering good quality comprehensive primary care. By cataloguing these, bringing together the policies and practices and amassing data which reflects the changing health picture, other communities across the continent can aspire to – and achieve – better integrated primary care services. That way Universal Health Coverage is achievable.

There is a view in global health development that ‘off the shelf’ solutions cannot work: they are not sufficiently representative of the particular demographics, poverty levels, determinants of health, topography and health systems from country to country. That may well be the case. But if there is any chance of roll-out of good initiatives, it is more likely to be successful if fellow Africans can show the way, transfer skills and knowledge from their own country experience, and help to shape policy and practice for future primary care systems which are based on the collaborative working of primary care teams.

While everyone within the family of primary care wants to see effective, affordable, integrated person-centred primary care services globally, it is a fair assumption that if we can support the effort to get it right in Africa it will probably be achievable in most other places.
With the active engagement of WHO, both centrally and the committed team in WHO AFRO, WONCA can lead the way in developing collaborations with our primary care colleagues, to prove that delivering continuous, comprehensive primary care services through qualified primary care teams will result in the best outcomes for patients and communities.

If you want to follow the work of AfroPHC or contribute to its development, please follow the link and get involved.

[1] Millennium Development Goals
[2} Atlas of African Health Statistics 2016, WHO Regional Office for Africa, 2016
[3] Aluttis, C., Bishaw, T., & Frank, M. W. (2014). global. Global Health Action, 7, 23611. [Available at accessed 24 August 2019]