Promoting South Asian primary care research and projecting family medicine practitioner-scholars: A matter of critical importance

ABSTRACT

South Asia, constituting India, Pakistan, Bangladesh, Nepal, Sri Lanka and Bhutan represents the most populous region in the world burdened with significant multilevel poverty. Primary care is well-documented to reduce the burden of diseases (both chronic and acute) and associated morbidity and mortality; be cost-effective and improve health outcomes and health equity for both individuals and populations. Any field, for it to stay relevant and to effectively achieve its stated mission, needs to produce its own knowledge through research. This translates into patient care, practice models, education, and advocacy for health systems strengthening and reform. In primary care, weaving experiential wisdom with clinical evidence lies at the heart of translation. In this editorial, we highlight: a) that local context, in terms of geography, community, culture, language and beliefs, influences the clinical context and practice and therefore research. Thus, relying on primary care research done elsewhere in the globe will not suffice; b) effective primary care is based on a generalist approach that involves certain ways of being, knowing, perceiving, and doing guided by the values of humility and intellectual curiosity, diversity and inclusion, equity, holistic approach to evidence, integrity, transparency, accountability and adaptability, and communication; and c) that the South Asian Region (SAR) has a number of groups experimenting and innovating with various healthcare delivery systems, much of which is not known to the larger field. The WONCA SAR Primary Care Research Network has been set up to facilitate and support scholarship, writing, and publication in primary care especially by practising family physicians. In conclusion, it will be critical to simultaneously promote grounded theory research that integrates both the family medicine/primary care perspective and the voices of families and address the ‘hidden curriculum’ that shapes the attitudes and aspirations of young doctors at both the undergraduate and postgraduate level. Family Physicians treat a variety of patients on a daily basis, in order to improve the quality of care and impact of primary care, it is imperative that the understanding and application of research is enhanced by specialists of this discipline.

South Asia and Primary Care: The Challenges of Enormous Scale, Deep Complexity, and Diverse Contexts

South Asia, constituting India, Pakistan, Bangladesh, Nepal, Sri Lanka, and Bhutan, represents the most populous region in the world. Furthermore, there is multilevel poverty in this region. As per the Poverty and Shared Prosperity Report 2018, 216 million people in South Asia fall in the category of “extreme poor,” accounting for 29% of the extreme poor worldwide.[1] The region is also plagued by urban-rural maldistribution and a burgeoning burden of noncommunicable diseases (NCDs).

Primary care is well-documented to (a) reduce the burden of diseases (both chronic and acute) and associated morbidity and mortality[2,3], (b) be cost-effective, and (c) improve health outcomes and health equity for both individuals and populations. Therefore, it is crucial to push for the strengthening of primary care to improve health outcomes. Unfortunately, despite the obvious need, the field of primary care and family medicine in this region is still in the nascent stage.

Primary care and family medicine can be strengthened through research, clinical audit, and evidence-based practices. Any field, for it to stay relevant and to effectively achieve its stated mission, needs to produce its own knowledge through research. This translates into patient care, practice models, education, and advocacy for health systems strengthening and reform.

Primary Care Research Needs to Emerge from Local Practice Contexts

In primary care, weaving experiential wisdom with clinical evidence lies at the heart of translation. The local context, in terms of geography, community, culture, language, and beliefs, influences the clinical context, practice, and, therefore, research. Thus, relying on primary care research done elsewhere in the globe will not suffice for clinical practice to be done in one’s own local context. It is thus critical to record, report, interpret, and determine local determinants and how they influence outcomes in the local context. Sharing this knowledge and experience is also critical to training the next generation of clinicians in primary care. Thus, primary care research done by primary care practitioners at primary care practices in the local context is a priority.

The Nature and Guiding Values of Generalist Inquiry (Family Practice Research)

As elucidated by Stange et al., “Effective primary care is based on a generalist approach that involves certain ways of being, knowing, perceiving, and doing.” Specifically, Generalist ways of being include an open stance that is receptive to diverse perspectives and co-created knowledge. It also involves humility that comes from being connected in key relationships. Generalist ways of knowing require broad knowledge of self, others, systems, the natural world, and their interconnectedness. Generalist ways of perceiving involve seeing the world in ways that foster integration—scanning and prioritising, then directing attention to the highest priority in that moment—in many moments over time, focusing on the particulars while keeping the whole in view. Generalist ways of doing this involve prioritised, joined-up action that engages with the most important parts in context, often doing multiple low-level tasks to enable higher-level integrative action over time—iterating among breadth/depth, subjective/objective, parts/whole, and action/reflection in service to a particular person and situation.[4]

Guiding Values of Primary Care Research

1. Humility and Intellectual Curiosity

   Family medicine practitioner-scholars approach conversation, hypotheses, and partnership with humility (rather than hubris), deliberately seeking out new and differing ideas with an open mind and curiosity. This also involves questioning the status quo externally in the world around us and internally in our clinical care protocols and institutional operations.

2. Diversity and Inclusion

   Family medicine practitioner-scholars believe that diversity in representation (in terms of co-investigators, disciplines, stages of career, stakeholders, etc.) and thought brings greater rigour and value to our work and facilitates innovation, translation, and quality. Patients and communities need to be seen as stakeholders and collaborators in primary care research.

3. Equity

   The belief that everyone should have equitable access to health care is a guiding value to primary care scholarship.

4. Holistic Approach to Evidence

   Family medicine practitioner-scholars need to take a holistic approach to evidence, valuing data and evaluation while being cognizant of the dearth of data in some settings and the limitations of well-established data-gathering frameworks from well-resourced settings.

5. Integrity

   Primary care research should support the right actions, by the right actors, using the right methods, in line with the core values of primary care.

6. Transparency

   Family medicine practitioner-scholars should be committed to transparent scientific research and publication practices.

7. Accountability and Adaptability

   Family medicine practitioner-scholars are first and foremost accountable to the communities they serve. This requires regular introspection to ensure that the insights gained through research are translated back into better care, services, and management of funding and resources for patients and communities.

8. Communication

   Family medicine practitioner-scholars should cultivate open, honest, and direct communication and also strive to be supportive and inclusive of diverse members who represent diverse communication styles and languages.

Adapted from the Global Engagement Network for Primary Health Care (GEN-PHC) drafted by Esther Johnston, Bassim Birkland, Ramakrishna Prasad, Klaus Pressentin, Annika Carlson, and Shailendra Prasad.

Multiple Obstacles Challenge the Ability to Perform Primary Care Research

An analysis published in 2016 comparing the health systems of five countries, namely Bangladesh, India, Nepal, Pakistan, and Sri Lanka, in the South Asia region (SAR) identified several factors that prevented the strengthening of primary care in these countries: lack of government/political will, financial support (healthcare budget), health regulations, basic resources (human and material), communication between policymakers and community (no bottom-up approach) and support for universal health coverage.[5,6]

One of the leading problems is the scarcity of clinical data. Effective maintenance and management of health records, for instance, documentation of clinical information, storage, retrieving, transferring, and protecting, is essential for a successful research project. Furthermore, translation of research into clinical practice requires a critical appraisal of literature, developing research-related networks, and attracting funding.

Moreover, the ground reality is that a vast majority of practising primary care physicians in the SAR do not undergo formal structured postgraduate training, and hence, their capacity to evaluate research is limited. Research remains a neglected area even in 4-year structured postgraduate residency programmes. Utilisation and application of research-informed clinical guidelines generated from the actual context of practice are linked with standards of care developed from research efforts. Due to the deficiency of this component, the quality of care is hugely compromised [Box 1].

Box 1.

Lists several key priority areas for primary care research in South Asia

Important Focus Areas for Primary Care Research
Primary care practice: Evaluate payment models and their impact to increase access to healthcare; creating practice groups and networks to share knowledge and resources; case studies; surveys/interviews on perceptions, skills, and knowledge of groups of interest; the prevalence of specific conditions.
Clinical governance: Data registry creation, auditable data records, communication pathways, risk mitigation plans, Evaluate and improve quality of care through accreditation,
Reforms in medical education related to primary care: The current medical education system does not give adequate exposure to the students in the practice of primary health care with professional identity, mentorship, peer recognition (in the medical profession), training is effective teamwork, and career growth. The practice of family medicine and primary health care that is accountable and addresses needs at the point of first contact, based on the continuity of the provider-patient relationship, is comprehensive, coordinated, and sensitive to the local context is not experienced by students or young health professionals.
Equitable development of primary care systems in low and middle-income countries (LMICs): Implementation research on advancing equitable, high quality, and family-centred comprehensive primary health care (CPHC) services.
Capacity building and human resources innovations: Task sharing activities to reduce unequal burdens; Establishment of point-of-care diagnostic services; Determine trends in the supply, training and distribution of the primary care workforce; To appraise workforce shortages and maldistribution.
Technology innovations and experiences: Clinical validation of point-of-care tests; electronic medical records.
The role of the family physician in urban and rural practice: FPs play several roles, including (1) Providing direct clinical care; (2) Consultant to nurses, interns, junior medical officers and community health workers; (3) Capacity builder; (4) Supervisor; (5) Clinical governance/continuous quality improvement (CQI) lead; and 6) Champion of COPC. These demand a range of clinical skills, social skills, leadership skills and the ability to work in teams, understand community needs, and engage with the community actively.
Quality improvement: Improving adherence to medicines, improving vaccination rates among select populations, decreasing loss-to-follow-up, improving linkage to social services for particular groups or conditions, measuring the number of individuals with likely viral infections dosed with antibiotics, etc.
Health systems design using the principles of family medicine: (A) Advancing the 5 Cs (comprehensive, first contact, coordinated, continuous, and context) of primary care.
(B) Grounded implementation science informed design and implementation of primary care services and capacity building of primary care teams.
(C) Education/fostering learning systems that incorporate Family Medicine physicians and promote interprofessional learning, collaboration, and teamwork.
(D) Focus on faculty development, leadership and governance training
among family physicians. (E) Accreditation of primary care practices.

Efforts by WONCA SAR

WONCA is the World Organization of Family Doctors, a global organisation representing family physicians (FPs) and general practitioners (GPs).

Since Nov 2021, as a part of the current leadership committee of WONCA South Asia, we have taken several concrete steps to build the foundation for primary care research in South Asia.

Although primary care as a field is still underdeveloped in South Asia, the region has a number of groups experimenting with various healthcare delivery systems, much of which is not known to the larger field. To focus on the above, we have worked towards building and participating in coalitions of value, impact, and scale that engage in cross-cutting and interdisciplinary learning across education, social entrepreneurship, business, administration, policy-making, technology, and other sectors. We have also supported the idea of the WONCA SAR Primary Care Research Network serving as an incubation space for primary care research, writing, and education by facilitating and supporting scholarship, writing, and publication in primary care, especially among medical students, family medicine residents and faculty, and practising FPs and GPs.

The path forward: Nurturing family medicine practitioner-scholars who can lead future action, research, policy, and advocacy to strengthen primary care in South Asia.

In conclusion, it will be critical to simultaneously (a) promote grounded research that integrates both the family medicine/primary care perspective and the voices of families and (b) address the “hidden curriculum” that shapes the attitudes and aspirations of young doctors at both the undergraduate and postgraduate level.

List of Abbreviations

FP, family physicians; GP, general practitioners; LMICs, low and middle-income countries; HICs, high-income countries; WONCA, World Organization of Family Doctors; NCDs, noncommunicable diseases; SAR, South Asia region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.