African Family Medicine
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* Raymond Downing

*To the Editor:* “Shifting the world's paradigm to ‘primary care access for all'” implies that family medicine provides an excellent means to facilitate this shift, even in Africa. Indeed, the evidence for the efficacy of primary care systems in improving health in the industrialized world is clear. Montegut1 reviews 6 “practice characteristics” that are related to better health outcomes, and Beasley et al2 describe 4 of them in some detail. The implication is that if primary care generally, and family medicine specifically, is to lead to better health outcomes, it should at least comprise these characteristics. So how closely does this fit with family medicine as it is developing in Africa?

It is difficult to say whether these 6 characteristics will be as beneficial in Africa; studies need to be done in Africa asking this question. But my experience in a new family medicine training program in Kenya, together with at least 1 continent-wide survey (so far unpublished), suggest that these particular characteristics are not always the first priorities for African family medicine.

First contact care and “gate-keeping,” for example, is not a common characteristic of African family medicine; this is often done by nurses or physician assistant-level providers.3 Longitudinal care is very difficult where chronic disease is uncommon, and the majority of patients come for acute episodic care. Comprehensive care is a goal, but African family physicians do not rank “preventive medicine” as their first priority. Rather, they are concerned with being good generalists, and in most African settings, this involves not only inpatient care but also major emergency surgery.

Of course it may be that these 6 characteristics could be conducted by other parts of the primary care systems in Africa, ultimately leading to improved health outcomes. Yet I suspect that in countries where half of the people live on less than a dollar a day, where roads are poor and transport expensive, where people do not have habits of “check-ups” or daily medicine-taking, these 6 characteristics may not be as important in improving health as will overall improvements in their economies. To expect African family medicine to carry out the agenda of primary care described in these articles is to ask of it what it has neither chosen nor can deliver.

## References

1.  Montegut AJ. To achieve “health for all” we must shift the world's paradigm to “primary care access for all.” J Am Board Fam Med 2007; 20: 514–7.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjAvNi81MTQiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzIxLzIvMTY5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Beasley JW, Starfield B, van Weel C, Rosser WW, Haq CL. Global health and primary care research. J Am Board Fam Med 2007; 20: 518–26.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjAvNi81MTgiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzIxLzIvMTY5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  Ssenyonga R, Seremba E. Family medicine's role in health care systems in sub-saharan africa: Uganda as an example. Fam Med 2007; 39(9): 623–6.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=17932794&link_type=MED&atom=%2Fjabfp%2F21%2F2%2F169.atom)