Family physicians bring expertise and capacity building to clinical practices. Making family physicians a part of primary care teams will improve the coverage and quality of healthcare in communities.
In LMICs, when governments have a commitment to UHC, primary care is often provided by less trained, more affordable, and more available healthcare workers. Photo: Rawpixel
Family physicians are important companions on the path to universal health coverage (UHC). In low- and middle-income countries (LMICs) we tread the path with a team of people intended to deliver high-quality primary care and cover the whole population. Our fellow travelers include nurse practitioners, physician assistants, and community health workers.
In high-income countries, general practitioners or family physicians are doctors with postgraduate training in family medicine who typically offer first contact access to primary care. In countries such as the US, the number of primary care physicians per population has been strongly linked to improved mortality and morbidity. In countries such as Portugal, the introduction of a national health system based on registration with a family physician was linked to significant improvements in maternal and child mortality.
In a 2008 World Health Report, the World Health Organization (WHO) commented that “primary care has been defined, described and studied extensively in well-resourced contexts, often with reference to physicians with a specialization in family medicine or general practice. These descriptions provide a far more ambitious agenda than the unacceptably restrictive and off-putting primary-care recipes that have been touted for low-income countries”.
In LMICs, when governments have a commitment to UHC, primary care is often provided by less trained, more affordable, and more available healthcare workers, such as nurse practitioners and physician assistants. For example, an upper middle-income country such as South Africa opted for nurse-led primary care after apartheid. Nurses are trained for one year to function as clinicians and often work with an algorithmic approach that lacks confidence and deeper expertise. In South Africa, we now have 3,500 primary care facilities within 5km of 90% of the population. Subsequently, the Ideal Clinic initiative has set a goal of every primary care facility having access to a doctor.
In other countries, such as Malawi, primary care has been delivered through selective vertical programmes, often linked to donor funding for specific conditions or diseases, causing resources to be unequally distributed. Many countries remain hospital-centric, with primary care the Cinderella of the health system; so while coverage improves in many LMICs, poor infrastructure and lack of equipment, digital technology, and effective health information systems continue to restrict the quality of primary care. In the private sector, primary care clinics may also lack comprehensiveness and continuity as doctors are not trained in family medicine and clinics are designed to feed patients to the hospital. In urban settings there is a smorgasbord of primary care providers, from allopathic to alternative and traditional practitioners, and many of them are poorly regulated.
Including family physicians as part of the primary care team in LMICs can help balance coverage and quality. In countries such as Brazil, family health care teams have championed community-orientated primary care. These are teams of family physicians, nurses, and community health workers. Such integration of primary care with public health approaches has had major health benefits, such as reduced infant and child mortality.
The primary hospital and its primary care platform are intimately linked in many health systems and in LMICs the family physician must straddle both these settings. In the Western Cape province of South Africa, practitioners at the primary hospital lacked the skills that family physicians had, particularly in obstetrics, surgery, and anaesthetics; this motivated policymakers to include family physicians in the health system. Now family physicians are instrumental in participating in and leading clinical teams in primary care facilities and primary hospitals.
Likewise, a review of the contribution of family physicians to health systems in sub-Saharan Africa identified the importance of the 'five Cs': clinician, consultant, capacity builder, clinical trainer, and clinical governance leader.
At heart family physicians are clinicians, and through their postgraduate training in family medicine they bring a more advanced skill set closer to the community. For example, patients with complicated multimorbidity or diagnostic dilemmas, or who need minor surgery, can be helped at their primary care facility. Family physicians may be permanent full-time team members at larger health centres, or they might provide weekly outreach from the primary hospital in smaller rural facilities. Family physicians act as consultants to the team, rather than the first point of contact as in high-income settings. Nurses or physician assistants can refer patients within primary care to see the family physician.
Family physicians capacitate the clinical team through their role as consultant and by providing clinical support to more junior colleagues. Colleagues may feel more confident to practice, knowing that someone is available to assist should there be problems or complications. In addition, family physicians take responsibility for continuing professional development and clinical teaching.
As family physicians join these clinical teams, there is an opportunity for more formal clinical training and teaching. Medical students, registrars, and interns can be placed in district-level health services under the supervision of family physicians. This also enables higher education institutions to be more socially responsible and prepare health professionals better for the needs of the population outside of tertiary hospitals. Family physicians frequently help train nurse practitioners and physician assistants. This allows the health system to become a place of learning, reflection, evidence-based practice, and innovation.
Finally, family physicians as senior clinicians lead the improvement of quality and clinical governance. Implementing systems to improve quality goes beyond clinical training and teaching. Activities may include audits and feedback, implementation of clinical guidelines, morbidity and mortality meetings, patient safety incidents, and reflection on routinely collected information such as investigations and prescribing. For example, antibiotic stewardship is a key activity. Because of their postgraduate training family physicians may bring a level of critical thinking and systems thinking that is needed to improve the quality of care.
Family physicians, therefore, are essential members of primary care teams in LMICs, and to the struggle for UHC.
The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.
Professor Bob Mash is a distinguished professor in family medicine and primary care at Stellenbosch University in South Africa, serving as executive head of the Department of Family and Emergency Medicine. An NRF-rated researcher and international member of the USA National Academy of Medicine, he is editor-in-chief of the African Journal of Primary Health Care and Family Medicine. He coordinates the PRIMAFAMED network in sub-Saharan Africa and is the president-elect of the World Organization of Family Doctors African Region.
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