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Editorials

Primary healthcare is cornerstone of universal health coverage

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2391 (Published 03 June 2019) Cite this as: BMJ 2019;365:l2391

Re: Primary healthcare is cornerstone of universal health coverage

With reference to the editorial “Primary health care is cornerstone of Universal Health Coverage” published in the BMJ of 3rd June 2019 and co-authored by yourself. (1)

We completely support the position that primary health care (PHC) is THE cornerstone of universal health coverage (UHC). PHC is the most effective and inclusive means to deliver health services and certainly does need wise investment. Current PHC systems are indeed inflexible and without resources to address social determinants of health. There is a need to re-invent primary care such that communities are at the centre of healthcare. We are convinced that community health workers (CHWs) are an essential part of the PHC team.
However, the statement on Rwanda that ‘stand-alone’ community health workers (CHWs) acting as “the functional link between communities and health care facilities, SUCH AS HOSPITALS” is expected to provide sustainable UHC disturbs us. The editorial does not mention that good quality primary care for patients before they reach hospitals is more cost-effective and that PHC is essentially a team approach.

The evidence for CHWs is that they are maximally effective when they are operating as part of an interdisciplinary team. (2) The World Health Assembly (WHA) Resolution 62.12:” 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 respond effectively to people’s health needs”. (3) This was reiterated by yourself at WHA72 where you stated: “Adopting approaches for health workforce development based on multidisciplinary teams with a diverse skills mix and optimal scopes of practice increases workforce productivity while responding to a wide range of population and community needs (4) and that “Community health workers should not be regarded as a way to save costs or as substitutes for health care professionals, but as an element of integrated primary health care teams”. (5)

While the article conflates the PHC approach in Ethiopia and Rwanda there is, in fact, a marked difference in the way PHC is being constructed between these two countries. Ethiopia supports an integrated team approach. (6) Health Extension Workers operate at health posts and refer patients to health centers with health officers when needed. Moreover, there is a strong effort in Ethiopia to train family doctors to strengthen the competencies of those at the first point of care. (7,8) There are many examples of countries across Africa where, in addition to investment in CHWs, reform in PHC teamwork and training of nursing/midwifery, associate clinicians/physician assistants and family doctors towards the same end is occurring. (9,10) A conference just hosted in Kampala, Uganda, 6-8th June 2019 by the African region of the World Organization of Family Doctors (WONCA) showed active interest and action towards family medicine development in more than 20 countries. Rwanda has proven the exception, with an embryonic family medicine programme suspended in 2012 by Dr. Agnes Binagwaho when she was the Rwandan Minister of Health. The rationale appeared to be the national priority of training hospital-based specialists. (11)

We are very grateful for the memorandum of understanding you, on behalf of WHO, signed with WONCA in January this year to support the development of family medicine as a key discipline underpinning modern cost-effective primary care. (12) We were most pleased with the active involvement of Dr. Prosper Tumusiime, representing WHO AFRO, at the WONCA Africa Conference in Kampala. He was clearly impressed by the youth and gender activism of family doctors. He actively embraced the MOU and a strong partnership between WHO AFRO and WONCA Africa are in the making. We publicly declare our commitment as family doctors to universal health coverage, primary health care and building the capacity of primary health care teams at scale in Africa. (https://www.woncaafrica.org/post/kampala-commitment-2019 ) (13) Communities in Africa, as everywhere in the world, must receive safe comprehensive primary health care. This can only be achieved if CHWs, essential as they are, are supported by a multi-professional team that is skilled to address the diversity and complexity of their health care needs in primary care. Global health inequities will continue unless we strive to achieve this not only for Africa but in low-and-middle-income countries across the world.

We urge you to champion the contribution of ALL health care workers in PHC, including professionals like nurses/midwives, clinicians/physician assistants, and family doctors. If we want to truly re-invent PHC to provide accessible, affordable, cost-effective, comprehensive, quality primary health care then we need teamwork including family doctors, especially in Africa and especially considering the resources of the whole health system. UHC built around hospitals, like in India and possibly Rwanda will be disastrous for Africa. We urge you to actively support our efforts in Africa to achieve UHC and leave no one behind.

We also urge you to approach authorities in Rwanda to resurrect their family medicine training programme and to reconsider the role of family doctors in PHC teams.

References
1. Binagwaho A, Adhanom Ghebreyesus T. Primary healthcare is cornerstone of universal health coverage. BMJ. 2019;2391(June):l2391.
2. Kim K, Choi JS, Choi E, Nieman CL, Joo JH, Lin FR, et al. Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: A systematic review. Am J Public Health. 2016;106(4):e3–28.
3. Sixty-second World Health Assembly. Primary health care, including health system strengthening. World Health. Geneva: World Health Assembly; 2009.
4. Director-General. A72/12 Provisional agenda item 11.5- Universal health coverage. Primary health care towards universal health coverage. Geneva; 2019.
5. Director-General. A72/13 Provisional agenda item 11.5 - Universal health coverage Community health workers delivering primary health care: opportunities and challenges. World Health Organization. 2019.
6. Feysia B, Herbst CH, Lemma W, Soucat A. The Health Workforce in Ethiopia: A World Bank Study. Vol. 1, The World Bank. 2012. 1–63 p.
7. Philpott J, Cornelson B, Derbew M, Haq C, Kvach E, Mekasha A, et al. The Dawn of Family Medicine in Ethiopia. Fam Med. 2014;46(9):685–90.
8. Evensen A, Wondimagegn D, Zemenfes Ashebir D, Rouleau K, Haq C, Ghavam-Rassoul A, et al. Family Medicine in Ethiopia: Lessons from a Global Collaboration. J Am Board Fam Med. 2017;30(5):670–7.
9. Besigye IK, Namatovu JF. Scaling up Family Medicine in Uganda. African J Prim Heal Care Fam Med. 2014;6(1):1–3.
10. Chege P. Primary healthcare and family medicine in Kenya. African J Prim Heal Care Fam Med. 2014;6(1):74649129.
11. Flinkenflögel M, Kyamanywa P, Cubaka VK, Cotton P. The next generation of Rwandan physicians with a primary health care mindset. African J Prim Heal Care Fam Med. 2015;7(1):1–2.
12. Beste A. WONCA signs landmark MOU with the WHO | WONCA Europe [Internet]. WONCA Europe News. 2019 [cited 2019 Jun 14]. Available from: https://www.woncaeurope.org/news/wonca-signs-landmark-mou-with-the-who
13. WONCA Africa Conference 2019. Kampala Commitment 2019: [Internet]. [cited 2019 Jun 15]. Available from: https://www.woncaafrica.org/post/kampala-commitment-2019

Competing interests: No competing interests

15 June 2019
Donald Li
President
Prof. Jan De Maeseneer (Primafamed-Network), Prof. Amanda Howe (Immediate Past President of WONCA), Dr Viviana Martinez-Bianchi (WONCA-WHO Liaison), Prof Valerie Wass (Treasurer WONCA), Prof. Shabir Moosa (President WONCA Africa), Dr Henry Lawson (Past-President WONCA Africa), Dr. Joy Mugambi (Kenyan Association of Family Physicians), Dr. Jane Namatovu (Ugandan Association of Family Physicians), Dr Temitope Ilori (Society of Family Physicians of Nigeria), Dr Emmanuel Ati (The Society of Family Physicians of Ghana), Prof. Ian Couper (Ukwanda Centre for Rural Health South Africa), Prof. Bob Mash (South African Academy of Family Physicians), Dr Elizabeth Reji (WONCA Women in Africa), Dr Nana Kwame Ayisi-Boateng (Afriwon - Young Family Doctors in Africa).
World Organisation of Family Doctors (WONCA)
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