Malawi is a landlocked country with a population of 17 million. The delivery of the health care system is based on primary health care (PHC). The PHC structures are acceptable; however, the system is marked by maldistribution of resources, fragmentation of services and shortage of staff. This hampers the function of the set, well-meaning PHC frameworks. Family medicine offers training and retention of the PHC and rural workforce, harnessing clinical governance and capacity building. Family medicine’s role extends to involve advocacy for the PHC to improve its performance.
IntroductionCountries with strong primary healthcare (PHC) report better health outcomes, fewer hospital admissions and lower expenditure. People-centred care that delivers essential elements of primary care (PC) leads to improved health outcomes and reduced costs and disparities. Such outcomes underscore the need for validated instruments that measure the extent to which essential, evidence-based features of PC are available and applied to users; and to ensure quality care and provider accountability.MethodsA systematic scoping review method was used to identify peer-reviewed African studies and grey literature on PC performance measurement. The service delivery dimension in the Primary Healthcare Performance Initiative conceptual framework was used to identify key measurable components of PC.ResultsThe review identified 19 African studies and reports that address measuring elements of PC performance. 13 studies included eight nationally validated performance measuring instruments. Of the eight, the South African and Malawian versions of Primary Care Assessment Tool measured service delivery comprehensively and involved PC user, provider and manager stakeholders.Conclusion40 years after Alma Ata and despite strong evidence for people-centred care, significant gaps remain regarding use of validated instruments to measure PC performance in Africa; few validated instruments have been used. Agreement on indicators, fit-for-purpose validated instruments and harmonising existing instruments is needed. Rigorous performance-based research is necessary to inform policy, resource allocation, practice and health worker training; and to ensure access to high quality care in a universal health coverage (UHC) system—research with potential to promote socially responsive, accountable PHC in the true spirit of the Alma Ata and Astana Declarations.
Recent studies have found an increasing burden of noncommunicable diseases in sub-Saharan Africa. A compressive search of PubMed, Medline, EMBASE, and the World Health Organization Global Health Library databases was undertaken to identify studies reporting on the prevalence, risk factors, and interventions for hypertension and diabetes in Malawi. The findings from 23 included studies revealed a high burden of hypertension and diabetes in Malawi, with estimates ranging from 15.8% to 32.9% and from 2.4% to 5.6%, respectively. Associated risk factors included old age, tobacco smoking, excessive alcohol consumption, obesity, physical inactivity, high salt and sugar intake, low fruit and vegetable intake, high body mass index, and high waist-to-hip ratio. Certain antiretroviral therapy regimens were also associated with increased diabetes and hypertension risk in human immunodeficiency virus patient populations. Nationwide, the quality of clinical care was generally limited and demonstrated a need for innovative and targeted interventions to prevent, control, and treat noncommunicable diseases in Malawi. Noncommunicable diseases (NCDs)-including cancer, diabetes, cardiovascular diseases, and chronic lung diseases-account for >80% of all premature NCD deaths [1]. This burden is likely to become larger over the next decade as urbanization and lifestyle changes progress and the mean age of the population increases [2]. In sub-Saharan Africa, NCDs are projected to account for almost 50% of all deaths by 2030 [3], presenting a major barrier to development [2]. NCDs and their risk factors are becoming major public health problems in Africa [4]. Recent data in Malawi show a high burden of hypertension, diabetes, and their risk factors (including tobacco, alcohol, and physical inactivity, all of which are increasing in prevalence) in both urban and rural areas [5,6]. Increasingly, hypertension and diabetes has been affecting individuals of younger ages and of relatively low or normal body mass index [5]. Complications of hypertension and diabetes, such as heart failure, stroke, myocardial infarction, hyperglycemia, and renal failure, are common reasons for admissions to medical departments in Malawi [7].
This article analyses the development and implementation of family medicine training and practice in Malawi, with special attention given to its current status and the projected role the trained family physician will be expected to play in the future. The general aim of the paper is to briefly review the role of family physicians in rural areas, as well as to discuss the history of family medicine training in Malawi. The idea of formal family medicine training and practice in Malawi started as early as 2001 but did not come to fruition until 2011, with the start of the undergraduate clerkship in the fourth year of medical school at the University Of Malawi College Of Medicine. This energy was followed by the launch of a postgraduate training programme in early 2015. The challenges encountered in this endeavour are also reviewed. The paper concludes by discussing the expected role a Malawian family physician will play in the local context, considering the key roles that family physicians play elsewhere in Africa.
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