Primafamed Network - Africa statement

Scaling up Family Medicine (FM) and Primary Health Care (PHC) in Africa:

Statement of the Primafamed network (23 November 2012, Victoria Falls, Zimbabwe).

This document reflects the work at the 5th annual conference of the Primafamed-network. It provides an analysis of the PHC context in sub-Saharan Africa and strategic ways to strengthen PHC. Taking into account the diversity in Africa, not all issues, proposals, topics are relevant to all African countries. The document was adopted by consensus.

From 21 to 23 of November 2012, participants from 20 countries convened at the Fifth Annual Primafamed conference (www.primafamed.ugent.be) at Victoria Falls, Zimbabwe. The participants want to support fully the realization of the World Health Assembly (WHA) resolution 62.12, by contributing: “to train and retain adequate numbers of health workers, with appropriate skill-mix, including primary health care nurses, midwives, allied health professionals and family physicians, able to work in a multidisciplinary context, in cooperation with non-professional community health workers in order to respond effectively to people’s health needs”.
 
The participants recognize the importance of the worldwide demographic and epidemiological transitions and the impact on health of the global economic crises, which give rise to new challenges for healthcare providers in Africa. Moreover the participants stress the need for an integrated approach to comprehensive PHC in order to address the fragmentation of care and health systems as a consequence of vertical disease-oriented programmes (HIV, malaria, COPD, diabetes, etc.). They confirm their commitment to the realization of the WHA resolution 62.12[1]:  “to encourage that vertical programmes, including disease-specific programmes, are developed, integrated and implemented in the context of integrated primary health care”,  the WHO Global Health Workforce Strategy[2] and the WHA resolution 59.23: "Rapid Scaling Up of Health Workforce"[3].
 
Family physicians fully support African governments’ implementation of universal health coverage that is oriented towards guaranteeing the right to health for all. This includes implementing the Abuja Declaration of allocating 15% of budget to health; developing nationally socially oriented health insurance systems to provide universal access; single risk pools and adjusted capitated systems to ensure resources go to those who need it most; strong decentralized district health systems responsive to local communities; the inclusion and regulation of the private for-profit and non-for-profit sector as contracted providers; and innovative payments systems to drive improvement of quality in integrated primary healthcare teamwork to achieve Health for All.

The participants define the future of FM in the framework of the PHC system: a community-based team approach including nurses, family physicians, mid-level care workers (associate clinicians), health promoters and community health workers, that focuses on accessibility, connectedness, health promotion and disease prevention, comprehensiveness, continuity, and coordination, in the context of families and communities (as described in the Consensus Statement, Rustenburg 2009[4]).

Family physicians in Africa take responsibility for specific tasks in the district and in district/community hospitals, and need to be trained accordingly. The training of family physicians has to take place mainly in an inter-professional PHC-team-context in the district health system. Family physicians share responsibility for training of other health care workers in PHC.

Increasingly, PHC will have to address the problems arising in the context of multi-morbidity, and providing appropriate person- and people-centered care. Community oriented primary care (COPC) is an appropriate strategy embraced by African PHC-teams, to address upstream causes of ill-health, including behavioural, social and environmental determinants.

The departments and training institutions for FM commit to a socially accountable approach in order to respond to the workforce needs and to the requirements of the health care system. Training in family medicine is based on the acquisition of appropriate knowledge, skills and attitudes in the context of the community, with dominance of community based training in the programmes.

In terms of scaling up FM, a reflection is ongoing on the optimal duration of postgraduate training, which will vary in relation to the relevance of the undergraduate training and contextual factors such as the need to work in the district/community hospital[5]. One example that inspired the participants was the experience reported by Sudan (Faculty of Medicine of Gezira University and the Ministry of Health), that addresses the needs of the local population through a two-year training programme in the community, supported by e-learning, that involved 200 candidates. This is one example on which we need to reflect in order to develop optimal training programmes in each country. The reflection will include determination of the need to learn procedural skills (surgical, anaesthetic, etc.) in each country. These and other topics will be addressed in the process of mutual learning and exchange in the Primafamed network.

In order to scale up FM, concrete strategic actions should be developed, including the following:

• Convince Ministers of Health and Education, and leadership of medical schools that a significant proportion of the graduates (between 40 and 60 %) should be trained in FM and PHC;
•  The existing community service period should be integrated into the training programme of FM, in order to fast track the scaling up at a lower cost;
•  Define appropriate content and duration of the training programme in each country;
•  Prepare for lifelong learning and develop appropriate Continuous Professional Development.

Essential conditions to make this happen are:

• Ensure that all countries have training in family medicine and establish networks, synergies and collaborations to support African standards;
• Integrate exposure to PHC and FM in the undergraduate curriculum and provide role models for FM;
•  Establish well-equipped training complexes for PHC teams (PHC centres and related clinics, with the district hospital for referrals); creating an environment for transformative learning
•  Offer sufficient funded posts for residents/registrars;
•  Provide appropriate remuneration for family physicians and PHC-teams and attractive career-paths;
•  Develop training the trainer programmes, taking advantage of South-South cooperation;
•  Increase the budget for PHC;
•  Encourage NGOs and donors to invest in strengthening local PHC-systems (www.15by2015.org);
•  Implement population-oriented campaigns to promote FM and PHC and stimulate cost effective use of health care services by the population.

If these conditions were fulfilled from today onwards, it is possible to train 30,000 new family physicians and tens of thousands of PHC professionals for PHC teams in sub-Saharan Africa in the next 10-years[6].

The participants stress that appropriate research in FM and PHC in Africa is essential, in order to substantially enlarge the evidence base for the issues highlighted in this document. This should be facilitated by the provision of specific funding by governments and NGOs, by building research capacity in academic departments of FM and PHC, and by developing an African FM and PHC-research network to support researchers and promote cross-country collaboration.

The delegates from the Primafamed-Network Conference want to engage in a regional strategy through dialogue at different levels: local level, the community, stakeholders, provinces, national government (Ministers of Health). Moreover at the international level they call upon the WHO-Africa region, African Union, Wonca, MEPI and other organisations to strengthen the commitment to the development of PHC and FM.

By doing so, the delegates are convinced that they can make a difference where it really matters, to contribute to a healthier future for Africa.

At the Primafamed Network-conference 2012 participants were coming from the following African countries: Botswana, Ethiopia, Ghana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria Rwanda, South Africa, Sudan, Swaziland, Uganda, Zambia, Zimbabwe and from countries from other continents: Belgium, Canada, Denmark, England, Ireland, Norway, The Netherlands, Scotland, USA.
 
Acknowledgement: the participants thank VLIRUOS, funded by the Belgian Government, and ICHO, the Flemish Interuniversity Cooperation for Training in Family Medicine, and Global Health through Education Training and Service (GHETS) for the sponsoring of the Primafamed-workshop in Vic Falls.
 
Correspondence: [email protected]
For more information on Primafamed, visit: www.primafamed.ugent.be

[1] http://www.who.int/hrh/resources/A62_12_EN.pdf
[2] http://www.who.int/hrh/documents/en/workforce_strategy.pdf
[3] http://www.who.int/workforcealliance/knowledge/resources/wha_scalingup/en/index.html
[4] Mash B, Reid S. Statement of consensus on Family Medicine in Africa. Afr J Prm Health Care Fam Med. 2010;2(1), Art. #151, 4 pages. DOI: 10.4102/ phcfm.v2i1.151 www.phcfm.org
[5] In a study on the principles of FM in Africa the need to perform common clinical procedures and operations appropriate to the district health system was a reality in 70% of the settings. Mash R, Downing R, Moosa S, De Maeseneer J. Exploring the key principles of Family Medicine in sub-Saharan Africa: international Delphi consensus process. SA Fam Pract 2008;50(3):60-65 www.safpj.co.za
[6] In the Sub-Saharan African Medical School Study, the authors calculated that: “The data suggest an estimated 10,000-11,000 graduates per year from medical schools in sub-Saharan Africa”(Mullan F et al. Medical schools in sub-Saharan Africa. The Lancet 2011:377:1113-1121). In the hypothesis that from 2013 onwards 50% of the graduates would be trained in Family Medicine, this would lead to 30000 new Family Physicians in Sub-Saharan Africa by 2020 in a 2-year programme and by 2022 in a 4-year programme (at higher cost). In Europe, the required post-graduate training for family medicine is 3 years (EC Directive 2005/36/EU).