Sub-Saharan Africa fast-tracks towards family medicine

Africa produces the world’s fastest athletes. Through the Primafed project, African nations demonstrate a similar propensity for speed, fast-tracking towards the development of family medicine in Sub-Saharan Africa (1). In the UK, family medicine/general practice, with personal doctors working in the community, referring when needed to hospital-based physicians and surgeons, took shape in the late 19th and early 20th centuries. It emerged as a separate medical speciality in the 1950s with the founding of the College of General Practitioners. The first Department of General Practice within a University was set up in 1956 at the University of Edinburgh, Scotland (2). General practice as a medical discipline gradually spread through Europe and the Commonwealth, and by the 1980s most medical faculties in universities in the UK, Scandinavia and northern Europe, Canada, Australia and New Zealand had academic departments of family medicine involved in both teaching and research. Following its inception as a discipline in the 1970s, PHC research grew fast. A study based on the PubMed database of general practice and PHC research outputs of 18 developed countries between 1975 and 2003 showed a vigorous increase in publications in most of the countries from a base of virtually nil. By 2003 New Zealand led the way with 20 publications per million inhabitants (3). In much of the developed world there is now inter-disciplinary team-based delivery of primary health care (PHC), with a comprehensive patient-centred approach of caring for patients in the context of their family and their community. There are established undergraduate and postgraduate curricula to ensure the training of well-qualified family doctors. An increasing quantity of PHC research is published in a wide range of journals both nationally and internationally. Since 2009 ‘Primary Health Care’ (including Family Medicine) has been an official subject heading in Index Medicus (4). Flinkelflogel et al. describe the Primafed project, in which 10 universities in eight Sub-Saharan countries have developed family medicine training programmes in the space of 2.5 years. This initiative is predicated on the understanding that PHC is the only realistic option to deliver equitable, affordable, accessible health care for all members of the community (5). Sub-Saharan Africa faces huge challenges. This region of the world has the largest percentage of the population living in poverty, with the greatest inequity between rich and poor (6). Poverty is exacerbated by many factors including population growth, low employment, famine and war. It leads to increased high health needs and reduced care access. Primafed has adopted a strategic approach, drawing on successful models from the developed world. This includes an overall framework, a network to enable sharing of information and resources, and local coordinators to ensure ongoing communication and implementation (7). They recognize the importance of a vertical progression from family medicine training in undergraduate curricula to postgraduate community-based training programmes, and a career pathway with sufficient and adequately remunerated positions for registrars and qualified family doctors. Promoting teamwork with other PHC workers is also a feature. The inter-relationship of clinical practice, teaching and research is recognized. The project incorporates components to monitor and evaluate their progress. An online open access journal serves as a vehicle for emerging researchers to disseminate their findings (8). The SWOT analysis reveals challenges faced in resource-rich countries but amplified in Africa: need for qualified family physician trainers, funding, resources, career opportunities, buy-in from hospital-based specialists and acceptance of family medicine as an essential discipline by authorities such as ministries of health. To achieve the goal of universal coverage of equitable, high quality care by well-trained PHC workers, a critical mass is required at all levels—sufficient recruitees, trainers, qualified family doctors to mentor others, through to PHC academics in the universities to provide the ongoing education and research needed to support the discipline. Primafed also reports considerable success. As well as the journal, by the end of the project eight of the 10 university departments had established postgraduate training programmes in well-equipped training hospitals. The authors conclude that there are many obstacles to sustaining family medicine training programmes and they have made slow progress. Indeed the need is great and the challenges are huge. However the Primafed project has made major advances in 2.5 years. While all might wish for more rapid growth, this paper reveals that their systems-based approach is fast-tracking Sub-Saharan Africa towards a trained PHC workforce designed to meet the health needs of their people. Hopefully resources will be available to sustain and extend this project into the future. Conflict of interest: none.

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