WALKING THE TALK
From dysfunctional gatekeeping to quality, comprehensive care for all Universal coverage of comprehensive PHC is not possible without a fit-for-purpose workforce. Significant reforms to workforce training are needed to offer comprehensive PHC services in line with countries’ universal health care (UHC) ambitions. Multiprofessional health education must be embedded within PHC settings; oriented to generalist practice; and focused on the unique knowledge, skills, and competencies required in a PHC setting. Further, universal provision of wide-ranging, high-quality PHC services requires the health workforce to be efficiently deployed (WHO 2018b). To achieve this, each cadre’s specific scope of practice needs to be aligned with providers’ comparative advantages within the multidisciplinary team unit. In mixed health systems, addressing workforce constraints to quality PHC may also require engaging and contracting private providers with public funds, while ensuring robust quality control.
A new paradigm for medical education In addition to technical knowledge and skills, PHC team members need a range of nontechnical skills grounded in the patient-provider relationship and in the community context. A mutually trusting and respectful relationship is central to high-quality care, irrespective of the setting or discipline. Health workers require adaptive expertise, which involves innovation in addressing uncertain, complex, and novel situations, balanced with efficiency that draws on routine knowledge. Clinical decision-making requires skills different from those needed in most large hospitals. Geographic distance from tertiary care centers, inequities in the availability of human and institutional resources, and people’s rising expectations for high-quality comprehensive care, even in economically constrained environments, create a new and challenging environment for PHC. These circumstances necessitate approaches to diagnosis and treatment that are grounded in clinical courage and are at once flexible and innovative, based on self-reliance, as well as efficient and effective use of resources.
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The transition to community team-based care models therefore requires a reorientation of the medical education system, particularly for physicians. The culture, pedagogy, and incentive structure of most medical education often work against the development of a fit-for-purpose primary care workforce. In most countries, the bulk of medical education and training is conducted in hospitals and other specialized settings that do not reflect PHC realities and service conditions. Most undergraduate medical education programs
