Luisa M Pettigrew

Primary health care and the Sustainable Development Goals

After the eight Millennium Development Goals that have shaped progress in the past 15 years, 17 Sustainable Development Goals (SDGs) were adopted by governments at the UN General Assembly in September, 2015. SDG3 explicitly relates to health—to “Ensure healthy lives and promote well-being for all at all ages”. This goal is translated into 13 targets: three relate to reproductive and child health; three to communicable diseases, non-communicable diseases, and addiction; two to environmental health; and one to achieving universal health coverage (UHC). Four further targets relate to tobacco control, vaccines and medicines, health fi nancing and workforce, and global health risk preparedness. When supported by strong public health policies and with aligned eff orts across social, economic, and political domains, primary health care has a central role in achievement of sustainable development. Although diff erences are inevitable between countries in the organisation of primary health care and the human resources available, many of the challenges outlined in SDG3—related to reproductive and child health, communicable diseases, chronic illnesses (including multimorbidity), addiction, and other mental health problems—can be addressed through a person-centred and population-based approach to primary health care. Delivery of vaccines and drugs needs a functioning primary care system. Well integrated and prepared primary health care has a key role in health emergency responsiveness, and it is essential for the achievement of UHC equitably and cost-eff ectively. Moreover, primary health care can contribute to the achievement of many of the 16 other SDGs; for example, its role in addressing the social determinants of health was underlined in the report Closing the Gap in a Generation. Primary care teams worldwide can provide examples from daily practice that illustrate their contribution across the SDGs, including helping to end poverty, improve nutrition, provide health education and promote lifelong learning, empower individuals and communities to reduce inequities and promote justice, enable access to safe water and sanitation, encourage productive and sustainable employment, foster innovation, advocate for healthy and sustainable living environments, and promote peaceful communities. Yet investment in realising the full potential of primary health care still seems elusive to many governments, policy makers, funders, and health-care providers. Therefore, 7 years after the World Health Report and The Lancet Series on primary health care, and 37 years since the Alma-Ata declaration, the absence of reference to primary health care in the SDGs and their targets seems a serious oversight. Two conclusions could be drawn: fi rst, that primary health care is dispensable and peripheral to achieving sustainable development; or, second, that primary health care is so integral to the path towards the SDGs that reference in a goal or target would undermine its cross-cutting role. We opt for the second conclusion, yet do so with apprehension, because one of the contributing factors to the documented failure of primary health care in many settings since the Alma-Ata declaration was “the scarcity of a proposed strategy for implementation and its monitoring for accountability and scale-up purposes”. This issue needs to be addressed in the development of implementation strategies for the SDGs. If the agenda is not explicit about how health systems with good-quality comprehensive primary care can be achieved, or how to measure progress towards this goal, we risk repeating the failures of the past. National governments and other stakeholders need to be ambitious in measuring progress towards delivery of primary health care that will address the SDGs. This monitoring includes the use of indicators that can capture For the report Closing the Gap in a Generation see http://www. who.int/social_determin ants/ thecommission/finalreport/en/ For the World Health Report and The Lancet Series on primary health care see http:// www.thelancet.com/series/almaata-rebirth-and-revision For Sustainable Development Goals (SDGs) see https:// sustainabledevelopment.un.org/ topics

No universal health coverage without primary health care

Universal health coverage is currently the aspiration of many countries worldwide. We commend Michael Reich and colleagues for analysing lessons learned from different country experiences, but we believe there is a crucial element neglected within the ongoing universal health coverage debate. Health-care system development requires more than financing and human resource considerations. Although essential, these components must be integrated into an overall framework for organising and delivering care that best meets population needs. Primary health care provides such a framework, builds the backbone of an effective health-care system, and can improve health, reduce growth in costs, and lower inequality. Strong orientation towards primary health care and its core principles (often outlined as fi rst contact, continuous, comprehensive, and coordinated care) is shown to be stable over time 4 and was often incorporated in the early days of many health-care systems that have a strong primary health-care orientation today. This observed stability makes the lack of focus on primary health care within the current universal health coverage debate an urgent issue. This is where universal health coverage should be reconnected with primary health care. To aim for universal health coverage and better population health should not remain a laudable intention. People living in countries presently moving towards universal health coverage—irrespective of their income level—should not suffer for decades because of an avoidable failure to secure a strong primary health-care orientation from the very beginning. We believe that the time to move the universal health coverage debate towards primary health care is now. We declare no competing interests.

Fit for the future? The place of global health in the UK's postgraduate medical training: a review.

Objectives That health is now global is increasingly accepted. However, a ‘mismatch between present professional competencies and the requirements of an increasingly interdependent world’ has been identified. Postgraduate training should take account of the increasingly global nature of health; this paper examines the extent to which they currently do. Design Trainees across 11 medical specialties reviewed the content of their postgraduate curriculum. Setting Not relevant. Partcipants None. Main outcome measures Competencies were coded as ‘UK’ (statement only relevant to UK work), ‘global’ (statement with an explicit reference to aspects of health outside the UK) or generic (relevant both to the UK and international settings). Results Six of the 11 curricula reviewed contained global health competencies. These covered the global burden or determinants of disease and appropriate policy responses. Only one College required trainees to ‘be aware of the World Health Organization’, or ‘know the local, national and international structures for health care’. These cross-cutting competencies have applicability to all specialties. All 11 curricula contained generic competencies where a global health perspective and/or experience could be advantageous, e.g. caring for migrant or culturally different patients. Conclusion Trainees in all specialties should achieve a minimum requirement of global health awareness. This can be achieved through a small number of common competencies that are consistent across core curricula. These should lead on from equivalent undergraduate competencies. Addressing the current gap in the global health content of postgraduate medical curricula will ensure that the UK has health professionals that are trained to meet the health challenges of the future.

Global health in UK postgraduate medical training

728 www.thelancet.com Vol 380 August 25, 2012 methodological training for members of the trial team and for research ethics committee members. Kenter and Cohen request that trial applications be reviewed by competent experts, while acknow ledging that such expertise is unlikely to be evenly distributed within the EU. They do not suggest how this gap should be fi lled. This challenge has been a major issue for one of the subgroups of our OECD Global Science Forum Working Group. We recommend the development of global core competencies as a compendium of required knowledge and skills for investigators and other members of the clinical trials team, research ethics committees, regulatory bodies, and sponsors. These training programmes should be open to the general public. Standardised, internationally recognised accredited qualifi cations in patient-oriented research should be defi ned in connection with these competencies. In this way, we can improve the training of everybody involved in clinical trials.

Combining general practice with international work: online survey of experiences of UK GPs.

Objectives To conduct an exploratory study to learn about the experiences of GPs who have undertaken international work. Design Cross-sectional survey Setting Online survey of UK-based GPs. Members of all UK RCGP faculties were invited to participate by email and the survey was publicised on the RCGP website Participants All UK-based GPs Main outcome measures Types of UK and international work undertaken, barriers, competencies gained, influence on career and future plans. Results The study identified 439 respondents, in a variety of GP roles at all career stages, who had undertaken international work in their role as a doctor. GPs are undertaking international work in both high and low/middle-income countries, engaging in a wide range of clinical and non-clinical activities. Respondents reported gaining a range of competencies from international work, which could be transferred back to the UK setting to a variable degree. Commonly cited barriers to international work were having to leave friends and family, and concerns regarding future employment and pension. Most reported that engaging in international work had influenced the direction of their career, with the largest proportion stating that they wish to work predominantly in the UK, with some international work in the future. Conclusion The study highlights the variety of ways in which UK GPs are combining UK general practice and international work, competencies gained with such work, and ability to transfer these back to the UK setting. Historical barriers to international work still exist and future research could further examine the value of such work.

The need for global primary care development indicators

Negotiations about how to measure attainment of the proposed health targets of the Sustainable Development Goals seem a complex and politically fraught process. It is important that there are adequate indicators to measure health-system strengthening to achieve the proposed Sustainable Development Goal 3: ”ensure healthy lives and promote well-being for all at all ages”. The Millennium Development Goals stimulated admirable improvements in health in many countries. However, these goals have recognised shortcomings, particularly related to fragmentation of health systems and health inequities. Although condition-specifi c measures of health outcomes are important indicators, the risk of focusing on these measures is that policy makers and funders pursue vertically oriented approaches to health care when resources are scarce and stakeholders’ specific interests prevail. Measures of health-system strengthening, including structure and process measures, should form a core part of the post-2015 development agenda. There is strong evidence and broad agreement that primary care is central to health-system strengthening. If appropriately planned and delivered, it is person-centred with a populationbased approach. Primary care, including multidisciplinary team-based models of family practice, can serve as the regular entry point into health-care systems and meet most health-care needs, including disease prevention and health promotion. Primary care helps to establish and maintain healthy populations in equitable and effi cient ways, and is essential to achieve universal health coverage. To strengthen primary care, clear and explicit indicators that monitor progress are needed, which measure the distinctive dimensions that make this type of care eff ective. These dimensions include comprehensiveness, coordination, and continuity of care. Indicators must measure safety and quality of primary care, as well as integration with the rest of the health system and workforce development. Although challenging, examples of internationally validated methods exist, such as the Primary Care Assessment Tools. With a commitment to the collection of relevant data, indicators transferable to varying country contexts and stages of primary care development can be implemented. Crucially, to achieve greater investment in this area than that at present, measures of primary care expenditure as a proportion of total health expenditure are needed. Health systems founded on strong primary care are essential to achieve the Sustainable Development Goals. We call on the UN and all other stakeholders to show an unambiguous commitment to the measurement and development of high-quality, comprehensive primary care. We must aim for this commitment in all countries, irrespective of level of income, and cannot aff ord to wait another 15 years to do so.

The postcode lottery of GP training: Time Out of Programme

As GP trainees, one of us was able to do an international Time Out of Programme Experience (OOPE); a scheme which allows UK general practice trainees to undertake a period of time out from their postgraduate training scheme to gain additional experience. I spent 2 years OOP: 1 year in a HIV treatment programme in KwaZulu-Natal, 3 months completing the Diploma in Tropical Medicine and Hygiene at the Liverpool School of Tropical Medicine, and the remainder of the time working in the UK as a locum. My year working in South Africa was a hugely formative experience, I …

The NHS and international medical graduates.

There is little doubt that the NHS would not have been sustainable since its inception had it not been for the on-going contribution of health professionals from overseas. It is clear also that international medical graduates (IMGs) are likely to encounter greater challenges to work in the UK than their UK counterparts. This has understandably been a subject of much contention for a multitude of reasons, not least due to allegations of the existence of conscious or subconscious discrimination. This paper does not aim to elicit the reasons why IMGs face greater challenges, nor to suggest how this should be addressed, as this has been done elsewhere and continues to be examined. The aim of this paper is to offer some context by providing an overview of the role of IMGs in the NHS, outlining the challenges they are known to face and placing this historical reliance on IMGs within the wider global discussion on workforce shortages and medical migration.

Incorporating Global Health and International Experience into Your Career

There is a great deal of enthusiasm among future and new GPs wishing to engage in global health-related activities and gain international experience. Altruism and idealism to advocate for greater worldwide equality in health, as well as a passion to learn and share experiences, are key motivating factors behind this. Yet, despite enthusiasm, incorporating global health and international experiences into your career can be challenging and may be met with resistance. This article will emphasize that incorporating global health and acquiring international experience throughout your career as a GP is both relevant and achievable. It will then go on to provide the information required in order to help take enthusiasm a stage further into action.

Tips for GP trainees wishing to undertake an international experience

International work … what does it mean these days? Is it largely medical aid or development work? A surf-laden Antipodean stint or a cutting-edge research fellowship overseas? Does it even need to take place outside the UK? Many GP trainees already have experience of international work by the time they reach vocational training; often during the undergraduate elective period. International experiences, in addition to those mentioned above, can range from expedition medicine, to health policy work within global organisations. Working with refugees and asylum seekers in the UK can provide a hugely valuable international experience without the need to venture abroad. On reaching GP training, fresh prospects can present themselves alongside existing opportunities. The Tooke report into Modernising Medical Careers confirms that time out programmes should be: > ‘… positively facilitated and encouraged … as it enriches the skill base and professional life of doctors, as well as promoting research and development and the global health agenda.’1 In addition to providing new perspectives on medicine, health systems, and the role of primary care in different countries and cultures, international work offers opportunities to develop a vast array of skills that are transferable to the UK setting. Among these are clinical, managerial, educational, and leadership components that contribute to a more effective and motivated NHS workforce.2–4 In the Global Health Partnerships report, Lord Crisp indicates that while the UK has much to offer other …