Identifying important research gaps in how primary health care is organised in low- and middle-income countries, and ways to address them Felicity Goodyear-Smith on behalf of the WONCA team Auckland, August 2018 Table of Contents Table of Tables 3 Table of Figures 3 Research team 4 Principal Investigator 4 Project manager 4 Co-investigators: (in alphabetical order) 4 Lead authors of implementation plans 5 WONCA Regional President advisers 5 Funding 6 Abbreviations 7 Introduction 8 Aims and Objectives 10 Methodology 10 Development of prioritised research questions 10 Stakeholder engagement 10 Study design 11 Analyses 12 Scoping literature review 13 Gap map 13 Research implementation plans 14 Results 14 Development of prioritised research questions 14 Scoping literature review 20 Gap map 23 Research implementation plans 25 Research Implementation Plan Brazil 26 Research Implementation Plan South Africa 30 Research Implementation Plan Malaysia 35 Research Implementation Plan Nigeria 40 Discussion 45 Summary of results and relationship to existing literature 45 Strengths of our study 46 Limitations 48 Implications going forward 48 References 50 Appendix 1 Priority and specific research areas & potential research questions 73 Appendix 2 Collective networks of the research team 77 Appendix 3 List of low and middle income countries 80 Appendix 4 Text for Round 1 Delphi panel for Qualtrics 84 Appendix 5 Codes for organisation / models of care 88 Appendix 6 Search terms for PHC and LMIC since 2003 89 Appendix 7 PHCPI conceptual framework 91 Appendix 8 Number of studies per LMIC country 92 2 Table of Tables Table 1 Numbers of enrolled participants residing and working in low and middle income countries ................................................................................................................................... 15 Table 2 Demographics of LMIC panel responders in each round ........................................... 16 Table 3 Research questions for PHC organisation rated for importance ................................. 17 Table 4 Number of studies per global region ........................................................................... 22 Table of Figures Figure 1 Countries of enrolled participants ............................................................................. 15 Figure 2 Coding matrix for PHC organisation ......................................................................... 21 Figure 3 Flow chart for search on PHC organisation .............................................................. 22 Figure 4 Number of studies from each LMIC ......................................................................... 23 Figure 5 Gap map of studies .................................................................................................... 24 3 Research team Principal Investigator Professor Felicity Goodyear-Smith Chair, WONCA Working Party on Research and Chair, International Committee of the North American Primary care research group. Academic head, Department of General Practice and Primary Health Care, School of Population Health, Tamaki Campus, 261 Morrin Road, Glen Innes Auckland 1072, New Zealand. Ph: +64 9 923 2357; [email protected] Project manager Mr Richard Fortier Department of General Practice & Primary Health Care, University of Auckland. Tel +64 9 923 7456 [email protected] Co-investigators: (in alphabetical order) Dr Andrew Bazemore Member of the WONCA Working Party on Research, and of the US National Academy of Medicine Director of the Robert Graham Center Policy Studies in Family Medicine & Primary Care, Washington DC, USA. [email protected] Ms Megan Coffman Robert Graham Center Policy Studies in Family Medicine & Primary Care, Washington DC, USA [email protected] Prof Amanda Howe President, World Organization of Family Doctors (WONCA); Professor of Primary Care, Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK. [email protected] Dr Hannah Jackson Fellow, Robert Graham Center Policy Studies in Family Medicine & Primary Care, Washington DC, USA. [email protected] Prof Michael Kidd Immediate past President of WONCA; Professor & Chair, Department of Family & Community Medicine, University of Toronto, Canada; Professorial Fellow, Murdoch Children’s Research Institute, The Royal Children’s Hospital Melbourne, Australia, and Honorary Professor of Global Primary Care, Southgate Institute for Health, Society and Equity, Flinders University, Australia [email protected] 4 Prof Robert L Phillips Member of the WONCA Working Party on Research; member of the US National Academy of Medicine. Vice President for Research and Policy of the American Board of Family Medicine, Lexington, KY, USA. [email protected] Assoc Prof Katherine Rouleau Associate Professor at the Department of Family & Community Medicine, Dalla Lana School of Public Health, University of Toronto, and Director of the Besrour Centre, Canada. [email protected] Prof Chris van Weel Past President of WONCA; Emeritus Professor of Family Medicine, Department of Primary and Community Care, Radboud Institute of Health Sciences, Nijmegen, The Netherlands and Honorary Professor of Primary Health Care Research, Department of Health Services Research and Policy, Australian National University, Canberra, Australia. [email protected] Lead authors of implementation plans Dr Sandro Rodrigues Batista Assistant Professor, Department of Community Medicine, Faculty of Medicine, Federal University of Goias, Goiânia, Brazil. [email protected] Prof Shabir Moosa Department of Family Medicine, University of the Witwatersrand, Johannesburg, South Africa. [email protected] Prof Sherina Mohd-Sidik Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra, Selangor, Malaysia. [email protected] Dr Aboi Madaki Associate Professor of Family Medicine and Deputy Director, Office of Research and Development, University of Jos, Jos, Nigeria. [email protected] WONCA Regional President advisers Prof Kanu Bala WONCA South Asia President and Member of WONCA Executive; Professor of Family Medicine of the University of Science & Technology Chittagong, and the Medical Director of the Bangladesh Institute of Family Medicine & Research, University of Science & Technology Chittagong, Dhaka, Bangladesh. [email protected] 5 Dr Henry Lawson WONCA Africa President and Member of WONCA Executive; family physician, Department of Community Health, School of Public Health, University of Ghana, Accra, Ghana. [email protected] Assoc Prof Maria Inez Padula Anderson WONCA Iberoamericana-CIMF President and Member of WONCA Executive; Associate Professor, Department of Family and Community Medicine, Rio de Janeiro State University, Rio De Janeiro, Brazil. [email protected] Funding This publication is based on research funded by Ariadne Labs through Brigham and Women’s Hospital, who is the recipient of a Bill & Melinda Gates Foundation grant. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation. 6 Abbreviations AAAPC Australasian Association of Academic Primary Care ABFM American Board of Family Medicine HIC High income country LIC Low income country LMIC Low and middle income country MIC Middle income country NAPCRG North American Primary Care Research Group NZ New Zealand OECD Organisation for Economic Co-operation and Development PHC Primary health care PHCPI Primary Health Care Performance Initiative PPP Public private partnership RGC Robert Graham Center SAPC Society for Academic Primary Care UK United Kingdom US United States WHO World Health Organization WONCA World Organization of Family Doctors WP-R Working Party on Research 7 Introduction Globally, it has long been recognised that timely access to affordable, acceptable health care from competent providers is crucial to achieving prevention, diagnosis, treatment and ongoing management of health problems.1-5 A strong primary health care (PHC) sector with an ongoing responsibility for integrating and addressing multiple care needs is key to doing this in a cost-effective and proactive way that maximises patient empowerment and addresses population health needs. Delivery of PHC requires a well-trained and well-resourced workforce which is adequate and appropriate for specific regional and national contexts. This may require capacity building of primary care physicians, to work in the context of interdisciplinary teams. PHC has to apply general principles under prevailing socio-economic cultural and health care conditions, with a focus on the priorities of the population under care. However, many countries are only just beginning to understand how to apply these principles, and have not yet evaluated the factors which could support effective PHC in their settings. This makes PHC research capacity in LMIC an essential feature of PHC development. In 1978, the Declaration signed at Alma-Ata identified the importance of primary health care, and called for it to be strengthened, particularly in low and middle income countries (LMIC).6 The initial response was the introduction of vertical programmes for specific populations and conditions,7 but contemporarily PHC is now expected to give access to a range of services spanning health promotion, prevention, acute and chronic care management, palliative care and rehabilitation for the whole population using multidisciplinary teams.8