Family Practice Vol. 17, No. 5, 361-363
© Oxford University Press 2000
Editorial |
Out of Africa: some lessons for general practice/family medicine in developed countries?
Department of Community Health Sciences, University of Edinburgh, 20 West Richmond Street, Edinburgh EH8 9DX, UK.
Murray SA. Out of Africa: some lessons for general practice/family medicine in developed countries? Family Practice 2000; 17: 361–363.
Received 26 January 2000; Accepted 16 May 2000.
Introduction
Many countries currently are looking to the UK for a model of effective and efficient primary care. I have had the privilege of being involved in developing primary care in East and West Africa as well as in the UK. Primary care in ‘developed’ countries may learn some fundamental lessons from developing countries, especially at a time when public involvement, community action and inter-sectoral liaison are being advocated in the UK. The following insights may be timely:
- primary health care is much wider than primary medical care
- community and individual care can be integrated together
- involving the public is essential
- nurses and other primary health care team members can adopt extended roles
- effective low cost care is possible
- holistic including spiritual care promotes health.
Primary health care (PHC) is much wider than primary medical care
The World Health Organization has advocated the broad concept of PHC for 25 years,1 and there are many examples of effective local and national primary health care programmes in Africa such as Zimbabwe in the 1970s. In developing countries, it is perhaps more immediately obvious that social and environmental factors are strong determinants of health. Inter-sectoral collaboration can be strong, and community participation can be a reality with volunteers who are involved in planning, assessing and even providing health services.2 I have sat at a village meeting where the local people were discussing their priorities; whether they should build a bridge, a clinic, or a church ... they decided on the bridge.
In Britain, by contrast, doctors and nurses in the community focus on primary medical care, providing accessible preventive and curative medical services. Such care is greatly appreciated by patients, but may have little impact on population health. If GPs and nurses in poorer communities in the UK wish to improve the health status of their patients, they have to work in co-ordination with other agencies in the statutory and voluntary sectors to address economic, social and environmental factors which are outside the conventional view of health services. The adoption of this philosophy and practice of primary health care has only taken place in exceptional practices. However, the UK government has set aside £300 million from the national lottery to establish a network of ‘healthy living centres’. Methods of carrying out and evaluating this initiative and also the development of ‘health action zones’ may be informed by successful projects in Africa.
Community-oriented primary care (COPC) can function well
The characteristic feature of COPC is that the health care of the community and individuals are brought together in a single integrated practice. COPC endeavours to identify the community's main health problems and implement defined programmes to deal with these, while at the same time providing clinical care for individuals. Thus an epidemiological or population perspective is brought to bear on individual clinical care while the clinical care informs the practitioners about wider issues. COPC was developed originally in rural South Africa,3 and currently has advocates in Israel, the USA4 and in England.
For full realization of COPC there should be
- high quality clinical care which is accessible, affordable and appropriate
- a comprehensive approach to health (physical, mental, social, spiritual and behavioural)
- a multidisciplinary team
- community involvement in its own health care
- co-operation of other services and agencies.
Initially, there should be a preliminary stage in which the population is defined and described. Field reconnaissance, while gathering qualitative and quantitative data, fosters public involvement. This works best where the target population is a community with a shared community sentiment and its own social institutions. The King's Fund has evaluated a number of pilot projects, and has developed a COPC workbook.5
Involving the public/community participation can work
When I worked at Chogoria Hospital in rural Kenya, a leader from a distant village presented me with a goat. He requested me to send a nurse to work in his village. The village leaders were prepared to raise funds to build a dispensary and the nurse's accommodation. They would also form an area health committee to help run the clinic, and to meet every few months to discuss local priorities. The committee would select local volunteer health workers to assist with health promotion and even service provision. In due course, after conducting a community profiling exercise to assess local needs, a new clinic was opened. Returning from Africa to Scotland, I found no such willingness of residents to be involved in their health care. Patients were passive recipients, so I sought out to apply a community development approach utilizing my African experiences.
Our expanded primary care team in Edinburgh carried out a similar community profiling exercise using the technique of rapid appraisal as learnt in Africa.6 For the last 5 years since then we have facilitated a ‘Health Forum’. Every 3 months, ~30 people who live or work in Dumbiedykes (a small central Edinburgh housing estate) meet together for sandwiches and to discuss what we can do together to address the most pressing issues which are adversely affecting people living there. Local residents enjoy meeting the Local Housing Officer, Social Worker, Parish Visitor, Health Visitor, Community Education Worker, Community Policeman and others, and the Forum has had some marked successes and failures in its work of local advocacy. After routing a bus into the area and getting some small play areas constructed, we more recently have helped local residents gain housing renovations. Empowering the local Residents' Committee with health data was instrumental in their success. We have also met with local psychiatrists and Housing Officers who were unaware of a concentration of people with mental health problems living in the area. Our practice-held prescribing and hospital utilization data confirmed the local residents' perceptions about this inequality. A more mixed community is now sought, and we now have a community psychiatric nurse based in the surgery.
Nurses and other PHC team members can adopt extended roles
In many parts of Africa, where doctors are few, nurses deliver most primary care. Nurses frequently are trained to provide comprehensive curative and preventative services independently, including maternal and child health and family planning at dispensaries and health centres. In Kenya in the 1980s, we used the Stott and Davies model of the potential of a consultation in such nurse training,7 and nurse-led opportunistic health promotion and family planning had a remarkably high uptake rate. Nurses proved very capable in performing the triage role at clinic level, referring to hospital appropriately, and were skilled in chronic disease management.
Extending the roles of practice team members may address the increasing workload in UK general practice, and increase individual job satisfaction. Many patients in my practice prefer to attend the nurse for family planning advice and provision,8 and are happy to attend a well-trained and supervised receptionist for phlebotomy.
Ensuring best value for limited money
If you are managing a hospital in Africa, and you are dependent largely on patient fees from poor people for finance, you have to consider with colleagues and the local people what services they can afford, and provide these as effectively as possible.9 X-rays and laboratory tests can be utilized sparingly, with greater reliance on clinical diagnostic skills. Medicine must also be affordable: an inhaler may cost a week's wage, and thus tablets may be more appropriate for asthma. As a clinician, the largely preventable deaths of neonates, children and young adults is hard to bear as health spend is so unjust, but local people accept their lot usually philosophically.
The spiritual dimension may be important to the patient
In Africa, local churches sponsor most hospitals outside the large cities and towns. The patient's spiritual nature is acknowledged as important, and people whose mortality and sense of meaning are challenged by illness often seek to discuss such issues with staff. Thus a holistic approach to health care is taken, trying to identify and meet whichever needs are most pressing to the patient at that point in time, whether physical, psychological, social or spiritual. Traditional healers can render emotional and psychological support, especially important in the field of HIV/AIDS in Africa, and are good at providing holistic care.
Conclusions
Our health care system and we as clinicians and individuals can learn much from overseas. If you have experienced PHC working in its fullness, seen the benefits of falling fertility and perinatal mortality rates, seen the public involved enthusiastically in their health care, you may wish your practice and Primary Care Group and Trust to embrace the paradigm of PHC. If you have worked with enrolled nurses providing comprehensive good quality primary care in harsh circumstances, you may develop an attitude that nurses with appropriate training could play a greatly extended role in the UK. Rationing is a daily clinical and management dilemma where resources are scarce, and people and clinicians in Africa have an open debate. Finally, as holistic practitioners, we must assess and be prepared to discuss whatever needs our patients express, whether physical, psychological, social or spiritual. Take a sabbatical, a voyage of discovery and learn by experiencing a different system. In Africa, there are wide horizons and a host of responses to enormous challenges from which we can learn.
References
1 World Health Organisation. Global Strategy for Health for All by the Year 2000. Geneva: WHO, 1981.
2 DeBoer CN, McNeil M. Hospital outreach community-based health care: the case of Chogoria, Kenya. Soc Sci Med 1989; 28: 1007–1017.
3 Tollman S. Community oriented primary care: origins, evolution, applications. Soc Sci Med 1991; 32: 633–642.
4 Nutting PA. Community-oriented Primary Care. Albuquerque: University of New Mexico Press, 1987.
5 Gilliam S, Plamping D, McClenahan J, Harries J. Community-orientated Primary Care. London: King Edward's Hospital Fund for London, 1994.
6
Murray SA, Tapson J, Turnbull L, McCallum J, Little A. Listening to local voices; adapting rapid appraisal to assess health and social needs in general practice. Br Med J 1994; 308: 698–700.
7 Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979; 29: 201–205.[Medline]
8 Murray SA, Paxton J. Nurses or doctors: patient choice in family planning. Health Bull 1993; 51: 393–398.
9 Sammon AM. An integrated approach to health care financing—the case of Chogoria Hospital. Trop Doct 1996; 26: 177–179.[Medline]
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