Reflections on family medicine and primary healthcare in sub-Saharan Africa

Primary healthcare (PHC) can be seen as a set of values and principles that guide the health system in its policy, leadership and governance, commitment to universal health coverage and primary care.1 Governance, economics and the primary care workforce are the key structural determinants of effective primary care systems.2 The African continent has 25% of the global disease burden, but only 3% of the world’s health workers and less than 1% of the world’s health expenditure.3 The burden of disease in Africa has historically been dominated by acute and infectious diseases such as malaria, diarrhoeal diseases, lower respiratory tract infections, tuberculosis and measles. Over the last 25 years, however, chronic communicable and non-communicable diseases, such as HIV/AIDS, ischaemic heart disease, stroke and diabetes have become major contributors to the burden of disease.4 Additional contributors include newer threats such as Ebola and global warming, conflicts and displacement of persons, issues of gender and poverty with high rates of interpersonal violence, disadvantage for women in education and earnings and continued high risks during pregnancy and childbirth. Government in Africa is often characterised by flawed democracies and authoritarian regimes, which may not prioritise healthcare.5 Few countries meet the target of 15% of general government expenditure on healthcare that was agreed in the Abuja Declaration of 2001.6 In low-income countries, there are fewer resources to go around, and those resources available are often concentrated in prestigious central referral hospitals. Most countries meet the WHO criteria for having a critical shortage of health workers, defined as fewer than 2.28 doctors, nurses and midwives per 1000 population.7 Health systems in many countries, such as Malawi, rely on mission hospitals, non-government organisations and external donors to fund and provide services.8 These agencies often drive vertical disease-orientated programmes, skew central planning …