Abstract
The Royal College of General Practitioners is committed to a strategic policy of seeking to improve global health through promoting strengthened systems of primary health care throughout the world and particularly in low-income countries and regions.
Barbara Starfield's pioneering research over an academic lifetime has established that countries with stronger systems of primary health care achieve better health outcomes at lower cost and with lower health inequity (Starfield, Shi, and Macinko, 2005). The most likely explanation for this very consistent finding is the ability of primary care to make the skills of broad-based diagnosis and the capacity to integrate care around the particular needs and context of individual patients and their families, universally available at the first point of contact with the health service. At its best, primary care medicine exemplifies ‘the flexible discretionary judgement that is necessary to adapt services to individual needs’ (Friedson, 1990).
Yet, for far too long, there has been a tacit and complacent assumption that effective systems of primary care, including a central role for GPs/family physicians, are too expensive for low-income countries. This persists despite the fact that these countries carry the greatest burden of disease and premature mortality and therefore have the greatest need for cost-effective health care.
The 2008 World Health Report entitled ‘Primary Care: Now More Than Ever’ [World Health Organisation (WHO, 2008)] marked a major breakthrough by including physicians in the proposed model of primary health care teams across the globe. The report urged a ‘far more ambitious agenda than the unacceptably restrictive and off-putting primary care recipes that have been touted for low-income countries’ and pointed out that ‘primary care demands teams of health professionals: physicians, nurse practitioners and assistants with specific and sophisticated biomedical and social skills— it is not acceptable that, in low-income countries, primary care would be synonymous with low-tech non-professional care for the rural poor who cannot afford any better’. Since then, countries such as Brazil and Thailand have succeeded in training large numbers of enthusiastic young primary care physicians as part of a commitment to providing universal, accessible and cost-effective health care.
So how can the college and its members help towards achieving these impressive goals? There is already undeniable energy and talent within the College's Junior International Committee but how best to harness this? For many, the most straightforward way of contributing seems to be spending time working in the front line of clinical care in a low-income country. Indeed, two Deaneries now provide the possibility of Out of Programme Experience during training in line with the recommendations of the Crisp Report (Crisp, 2007). This is a start, but there is still a long way to go. Yet, doctors from high-income countries, such as our own, need perhaps to be aware of the effects of what the novelist Tessa Hadley in her tribute to the great South African novelist Nadine Gordimer describes as ‘the conscientious unease of privilege, however impeccably liberal—the worm under the skin’ (Hadley, 2012).
The whole project of ‘aid’ has become ever more challenging and contested and anyone seeking to make a contribution should be aware of the dimensions of the debate. The Zambian economist Dambisa Moyo (Moyo, 2009) inverts the rallying cry of the American War of Independence: no taxation without representation. She argues persuasively that, without taxation, there can be no representation. The amount of foreign aid reaching most sub-Saharan African countries far outweighs the national income derived from systems of taxation and so governments find themselves more accountable to foreign donors than to their own populations. In health policy, this has played out in the development of vertical programmes orientated to specific diseases, funded by huge donations from institutions such as the Bill and Melinda Gates Foundation and the neglect of publicly funded primary health care systems accessible to the whole population. Doctors working in low-income countries undoubtedly benefit the lives of individual patients and so their contribution is clearly important but, in the long term, the benefit to the doctor, in terms of increased knowledge and skills (The International Health Links Centre (IHLC) & The London Deanery, 2011), seems likely to outweigh any sustainable gain for the low-income community. In the long term, it may well be more constructive for UK doctors to develop expertise in teaching and assessment.
There is much more that the College can achieve. Working through Wonca (the World Organisation of Family Doctors) and in collaboration with other global organizations, we can sustain the political pressure that supports the development of effective primary care systems across the world. The college already assists such development through its support for the education and assessment of GPs, perhaps most notably in the South Asia region and, as these programmes grow, there should be many opportunities for young doctors with the appropriate skills. The key is to bolster each country's own resources by enabling primary care doctors to thrive, to counter the age-old problem of low status in relation to hospital colleagues and to resist the obvious temptations of emigration. As always, we have a huge amount to offer but even more to learn.