Primary health care priorities needed in low- and middle-income countries – a bottom-up approach
Ricky Fortier, Graduate student in the Department of Family Medicine, McGill University
I was a part of an international multidisciplinary research team that explored priorities needed in primary health care (PHC) in low- and middle-income countries (LMICs). We found that a bottom-up approach, which gave our participants residing in LMICs a voice in the decision-making process of priorities needed in their countries, was vital to obtain results that can foster change, despite pushback from external voices who suggested that we implement a top-down approach. Simultaneously, we conducted two studies about (1) the organization and models of PHC and (2) the financing of PHC. Each involved a 3-round modified-Delphi technique consisting of 141 self-identifying PHC experts residing in 50 different LMICs representing six global regions: Africa, Asia Pacific, South Asia, Latin America and the Caribbean, Eastern Mediterranean, and Europe. Initially, engaging with our PHC expert panelists was significant as they best understood and had the greatest capacity to describe the current PHC climate in their settings.
Following the three modified-Delphi rounds, our expert panelists concluded that four research questions are most prudent to answer regarding the organization and models of PHC in LMICs. These four questions are:
1. What are the factors to be considered and negotiated for successful referral from primary to secondary care and back?
2. How should care be horizontally integrated and coordinated among the multidisciplinary PHC team?
3. How can the public and private sectors work more collaboratively to improve and integrate PHC coverage and prevent segmentation of the services?
4. How can different stakeholders (e.g., policy-makers, health system managers, health workforce organizations, academic institutions and communities) support and assist the primary healthcare workforce and successful team functioning?
The primary themes concerning the organization and models of care are (a) seeking avenues to better incorporate PHC in the health care system. For example, vertical movement between primary and secondary care, horizontally with other community-based services, and between public and private sectors. As well as (b) how can political, academic, and community-based organizations act with one another to strengthen PHC in LMICs. Research teams have been created and have developed implementation plans to answer the above-listed research questions as follows: Brazil (1), South Africa (2), Malaysia (3), and Nigeria (4), within the context of their country.
Simultaneous to our expert panelists generating the above research questions regarding the organization and models of care in their LMICs, they were also invited to create research questions regarding the financing of PHC in LMICs and came to a consensus on three top research questions:
1. What is the most appropriate payment system to increase access and availability of quality PHC?
2. What mechanisms have been found to be effective in persuading governments to invest in PHC that might be implemented?
3. What is the ideal proportion of the total healthcare budget that guarantees the development of quality PHC?
These questions emphasize payment and incentives for providing equal access care, action plans for political support of PHC, and the ideal balancing of PHC financing in the scope of total health spending. Research teams have been established to answer these research questions in Croatia (1), Kenya (2), and Turkey (3) and have established implementation plans with the context of their country.
PHC is still developing, both as a discipline and as an area of research in LMICs. Although PHC research priorities occur in LMICs, it’s regularly conducted with a top-down approach by governments and international organizations. When completed this way, the obtained results reflect little evidence of implementation. Our findings demonstrate the importance and appropriateness to undertake a bottom-up approach that includes health care practitioners, primary care academics, and policymakers residing in LMICs that direct the research. As an individual from a high-income country, it is my view that it’s significant to obtain the perspectives of those in LMICs to implement change. The bottom-up methodology applied in these two studies enabled identifying lacunas, developing research teams, and drafting implementation plans.
About the Author
Ricky Fortier is a second-year graduate student in Family Medicine at McGill University and holds a Bachelor of Science in Biopsychology from the University of Winnipeg. His research interests encompass PHC and wellbeing within marginalized populations, Indigenous peoples, and LMICs. Before his graduate studies, Ricky was employed and gained vast research experience at the University of Auckland, New Zealand, in the Department of General Practice and Primary Health Care, where he holds an Honorary Academic appointment.