PRIMARY CARE IN NIGERIA, THEN, NOW, AND THE FUTURE
Doctors have been working as generalists in primary care in Africa and Nigeria, and in rural hospitals without any further training, since the start of the 19th century.1 In Nigeria, postgraduate training in family medicine (previously known as general medical practice) began in 1981,1 although the Medical and Dental Council of Nigeria recognised it as a specialty when it established postgraduate medical training in the 1970s.2
Its popularity among young medical graduates has steadily risen since then to its present status where it is now the preferred specialty of choice in postgraduate residency training in Nigeria. Its graduates, Fellows of the Specialty in Nigeria, now number 313, and hold the same status as other specialists in terms of remuneration, career path, and privileges.3 Many Nigerians also hold the West African version of the degree from the West African College of Physicians.4 These fellows are distributed in all generalist settings, serving as consultant family physicians in general hospitals, university teaching hospitals, federal medical centres (tertiary hospitals), voluntary agency (mission) hospitals, and general practices.
Due to their broad training, they also fill in for surgeons, obstetricians, internal medicine specialists, and paediatricians when there are shortages in general hospitals and federal medical centres, as well as fulfilling their generalist roles.4 GPs, under the aegis of the Association of General and Private Medical Practitioners of Nigeria, are being encouraged to take the Diploma in Family Medicine course, run by the Faculty of Family Medicine (FFM) of the National Postgraduate Medical College (NPMC), so as to mainstream them into the family medicine movement.4
Although Nigeria has a strong culture of medical research in family medicine,4 undergraduate departments of this discipline have not been so fortunate in their growth, with only a handful of universities and colleges having undergraduate departments of family medicine. However, this is about to change, following closely on the heels of the World Health Organization acceptance of family physicians as important members of the primary healthcare team.5
Undergraduate medical students with a GP clinical preceptor.
The GPs are represented by the Association of General and Private Medical Practitioners of Nigeria. They asked for, and were given, the responsibility of providing postgraduate training in general medical practice (now family medicine) in the 1970s.4 Academic activities are maintained through mandatory continuing professional development activities during their monthly association meetings and are quite popular.
These GPs work closely with the postgraduate FFM at the NPMC and with the family medicine unit/departments in the universities nationwide to promote primary care. They are also at the forefront of promoting the National Health Insurance Scheme and Community Based Health Insurance Scheme in Nigeria.
The major challenges for primary care for the future are the implementation of undergraduate family medicine departments in all Nigerian universities, the strengthening of primary care research through MSc family medicine programmes in the universities, and the establishment of practice-based research.
In conclusion, family medicine and general practice, the areas that constitute primary medical care in Nigeria, are very strong, although there is much room for improvement, particularly in the areas of research and development.
REFERENCES
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THREE STEPS FORWARD AND ONE BACK — THE CURRENT STATE OF PRIMARY CARE IN POLAND
Poland joined the European Union (EU) on 1 May 2004 but the process of unification started many years before. Efforts to introduce family medicine as a specialty and discipline into the healthcare system began more than 10 years earlier.1 Before the collapse of communism, primary health care in Poland was provided by internists, paediatricians, physicians with other specialisations, and even those without any vocational training. In the early 1990s, the responsibilities of future family doctors were established. The pioneers of the discipline went to the UK, the Netherlands, Denmark, Ireland, and Spain to learn the principles of education, research, and the practice of family medicine. After returning to Poland they started training organisations for family doctors at all Polish medical universities, becoming a foundation for future departments of family medicine. Three-year (quickly extended to 4 years) residency-based vocational training for medical graduates and a retraining programme for experienced doctors was initiated.
Collegium Novum, Jagiellonian University, Krakow, Poland.
In 1995, from a small city in south-west Poland, Dr Wieslaw Iwanowski began the first independent but publicly-financed family practice in the country and continues to practise there to this day. During the next two decades thousands followed in his footsteps. Both educational and organisational endeavours, especially at the beginning of the changes, have been supported by the EU-funded programme PHARE (the pre-accession programmme for Poland and Hungary to join the EU) and a World Bank loan. The central government and local authorities also supported these efforts2,3
New organisational and financial arrangements have proven their worth.4,5 Tens of thousands of family doctors now run independent practices, gaining acceptance from their patients. Family medicine has achieved an academic standard similar to other disciplines6 and is now a mandatory part of the curriculum for all medical students at each medical university.
Medical education in Poland lasts for 6 years. At the Jagiellonian University Medical College in Krakow, students are exposed to family medicine throughout their entire education. Beginning after their second year, medical students spend 3 weeks (90 hours in total) during the summer participating in a clerkship. Fourth-year medical students are required to participate in a family medicine experience consisting of seminars and clinical exercises totalling 36 hours. Finally, sixth-year medical students spend 70 hours participating in a family medicine clerkship consisting of 1 week of seminars and 2 weeks of clinical experience in a general practice under the supervision of a family medicine physician. After the 3 weeks, students are then required to give two case presentations on patients encountered during their time in a general practice. Students enjoy this experience, considering it a valuable part of their medical education, proven by the fact that many of these students choose family medicine as their specialty once they graduate.
A future GP/family doctor is introduced to the primary care system by first spending a 6–8 week training period under supervision by a doctor at their clinic. This is followed by the completion of a hospital rotation, lasting for 2 years (including surgery, internal medicine, paediatrics, and other specialisations such as ophthalmology, laryngology, and dermatology). Residents returning to the primary care system then need to complete an additional 2 years of training at a primary care general practice. The process is completed with a written exam in Warsaw conducted twice a year and a practical exam conducted at regional locations.
However, there have been some recent changes. In 2014, the parliament passed a new law allowing all internists and paediatricians (even those without a single day of training in primary health care) to practise in primary health care on an equal basis with family physicians.7 It seems that political pressure from (mainly) paediatric lobbyists was stronger than that of common sense, scientific evidence, and expert arguments. The Polish healthcare system has the lowest number of physicians in the whole of the EU, one of the lowest healthcare expenditures, and struggles with numerous problems, but, in fact, primary health care was the only part of the system relatively well perceived by patients.8 It seems that the government wants to solve these issues by placing several new responsibilities on the shoulders of primary health care doctors without the relevant tools and resources, which may result in serious tensions in the near future.
Difficulties starting a new practice (for example, high investment costs, lack of incentives, time needed to generate a sufficient list of patients) and consistently increasing bureaucratic burdens are other problems that younger physicians will have to face. Many of them have decided to leave the country to practise abroad.
However, some of them returned bringing new ideas and experiences back to Poland and this new generation of trainees and young family doctors significantly contribute to the development of the discipline. Although not often able to start their own practice, they form a highly desirable workforce and are well-paid professionals. Along with more experienced colleagues, this new generation is involved in various activities of the College of Family Physicians in Poland, other scientific associations, and employers’ organisations, together forming a primary healthcare-oriented society advancing the development of family medicine.
Let’s keep our fingers crossed for their success.
- © British Journal of General Practice 2015
