In 1978 the World Health Organization (WHO) made a public declaration in Alma-Ata advocating the use of primary healthcare systems globally.1 Twenty-two years later the United Nations (UN) agreed eight Millennium Development Goals (MDGs) to be attained by 2015.2,3 Core to the delivery of them, although not explicitly mentioned, is the primary healthcare model as set out in the Alma-Ata Declaration. In 2008 the WHO Regional Office for Europe reiterated that effective primary health care was essential to the delivery of quality health services for individuals and populations by publishing the Talinn Charter.4 This too included a commitment to attain the Charter’s targets by 2015.
As we approach the 2015 deadlines for both the MDGs and the Talinn Charter, governments and policy makers are increasingly interested in primary health care. At the Royal College of General Practitioners (RCGP) we observe this by a steadily growing number of international requests to support primary care development. We are entering a critical window of political activity in health funding and global health systems reform.
The MDGs committed world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The goals related to the eradication of disease specifically drew international attention to communicable diseases (including HIV/AIDS, malaria, and tuberculosis) and focused resources on vertical models of health care for disease-specific diagnoses and treatment. This diverted attention away from the implementation of a horizontal model of primary health care with its less immediate yet longer-term benefits as demonstrated so clearly by Barbara Starfield.5 This imbalance in systems reform was recognised in 2012 when the UN General Assembly published a political declaration on the prevention and control of non-communicable diseases (NCDs).6 The document acknowledges the need to address the growing risk that NCDs will exceed communicable, maternal, perinatal, and nutritional diseases as the most common cause of death in sub-Saharan Africa (SSA) by 2030. Approximately 36 million of 57 million global deaths in 2008 were attributed to NCDs, principally cardiovascular disease, cancer, chronic respiratory disease, and diabetes. This included around 9 million deaths before the age of 60 years. Nearly 80% of these deaths occurred in developing countries.
Mortality rates from NCDs present an increasing global burden — one of the major challenges facing the 21st century — and addressing these will require sustained and organised effort for many decades to come.7 A horizontal system of integrated primary health care is essential for tackling them.8 A report by Harris and Haines, which evaluates the Brazilian primary healthcare system, provides a helpful case study.9 It demonstrates the improvement in health outcomes and cost effectiveness resultant on a shift from tertiary care to primary health care over a 15-year period. Hospital admissions due to stroke or diabetes were reduced by 25%.
INTERNATIONAL COLLABORATIONS TO BUILD CAPACITY AND CAPABILITY IN PRIMARY HEALTH CARE
We need more doctors and health workers in primary health care globally, to build the capacity and capability within countries, and to develop and maintain patient-focused primary care health services.
There are significant challenges to retaining medical staff particularly in low-to-middle income countries due to an internal and external ‘brain drain’. The internal brain drain is often due to employers, such as non-government organisations, who offer better terms and conditions of service within the same country. The external brain drain to other countries offering better salaries, but notably also, improved postgraduate education opportunities. A 2010 SSA medical school study reported that the principle reason that ambitious medical students gave for emigrating is to gain postgraduate medical education.10 Thus, the recruitment and retention of medical and health professionals in developing countries needs to be addressed.
The RCGP International Committee works collaboratively with governments and local medical and health educators in-country to build sustainable primary healthcare courses. This year we celebrate our 25th anniversary. Over the years the College has established formal links with seven international centres where we have accredited their primary health care higher education provision. The largest centre is in South Asia where almost 550 primary care doctors have become international members (MRCGP[INT]) of the RCGP. Each year we host a conference which brings together international medical leaders in primary health care to share best practice in developing the discipline. The 2012 meeting, planned for the first time to immediately precede the RCGP Annual Conference in Glasgow, will host 80 delegates from 20 countries. In the last 12 months we have also awarded the first international fellowships to international members: one from Kuwait and four from Oman.
A global view of society supports the principle that access to the highest available standard of health is a fundamental human right. It follows that being healthy enables a person to attain a good life. This principle is high on the agenda of many of our AiTs and First5 members who pioneered, in 2009, the establishment of a Junior International Committee. Their initiative is moving from strength to strength and the College is now poised, using the voice of these new members, to make a unique contribution.
In 2011 we launched our 10-year strategy Transforming our Approach to International Affairs.11 In it we set out the following six strategic priorities:
Moving global primary healthcare policy higher up the agenda of the RCGP, other specialities and other countries.
Increasing the quality of education and delivery of primary care.
Influencing European Union legislation and policy relevant to the training and delivery of primary health care.
Improving the governance and coordination of RCGP-led international activities.
Strengthening support for international and overseas members of the RCGP.
Increasing capacity and capability within the RCGP to deliver the strategy.
A major task is securing funds to support work in developing countries. The strategy places Africa as the prime goal for our work for the RCGP 60th anniversary year. In October we are launching a campaign with Voluntary Services Overseas (VSO) to raise £60 000 to support two GP volunteers to work alongside doctors and other primary healthcare workers in Sierra Leone. These GPs will be supported by two senior college volunteers experienced in education to provide mentoring and support while they are overseas. This will release time for local doctors and primary healthcare workers to attend courses to support their continuing professional development. RCGP Council’s agreement to raise funds voluntarily from members for this project potentially opens the path to increasingly effective and sustainable engagement with developing countries.
THE RCGP’S GLOBAL CENTRE FOR PRIMARY CARE
A core goal of our 10-year international strategy is to establish a Global Centre for Primary Care within the RCGP. This will form the basis of a sustainable infrastructure for the next generation of international GP leaders to raise our role in global health to a higher level.
The Global Centre for Primary Care will consolidate our international education and global health expertise to form an accessible research resource and international advisory service. The RCGP is in a unique position to build capacity and capability for primary health care by collaborating with medical and healthcare educators worldwide and support them to develop bespoke, context specific education, and training. We have 60 years experience as a professional body setting professional standards in general practice and our international committee has 25 years experience in international education and training in primary health care in collaboration with over 30 countries. We have a large evidence base to analyse. The College has played a significant role in building this. Expertise in whole-person medicine requires a holistic approach to the delivery of health care that puts the person and their problems at its heart. Medical generalism is a specialty that is designed around the needs of the patient wherever they live in the world.
Dealing proactively with those affected by NCDs is possible using a robust primary healthcare system and the associated multidisciplinary team. More doctors and healthcare workers internationally are seeking opportunities to learn how to diagnose and treat patients with complex social and health backgrounds and multiple comorbidities. This expertise is the central domain of the primary care doctor: the GP.
We anticipate that, when the RCGP 10-year international strategy matures in 2021, all GPs in training will expect to study global health as a core part of their curriculum and to apply their learning in an international clinical context. The RCGP’s Global Centre for Primary Care will offer political leverage and a research evidence base to enhance our international work. Governments and global health organisations are beginning to accept that primary care is the foundation of an effective health system and provides the greatest hope for reduction of global health inequalities worldwide. The Global Centre for Primary Care will play a lead role in this by working collaboratively to share experience in primary care internationally so that GPs are recognised as the clinical and research leaders in global health.
Notes
Provenance
Commissioned; not externally peer-reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2012