Dr Innocent Besigye and Dr Bob Mash from the Primary Care and Family Medicine Network for sub-Saharan Africa (Primafamed) talk about comprehensive primary health care in sub-Saharan Africa.
Measuring the comprehensiveness of primary care requires attention to services provided across the life-course, burden of disease and from health promotion to palliation. The Primary Health Care Performance Initiative (PHCPI) (https://improvingphc.org/explore-country-data) selected three indicators to try and measure comprehensiveness of primary care from routinely collected data at a national level. These included the availability of HIV and TB services, services for non-communicable disease and five reproductive-maternal-neonatal-child health (RMNCH) services. A number of countries in sub-Saharan Africa are collaborating with the PHCPI and the evaluation of their comprehensiveness is shown in the Table below. Overall it appears that services for RMNCH are most available, closely followed by services for infectious diseases. Services for non-communicable diseases are much less available and ranged from 6% of facilities in Ghana to 97% in South Africa. It was also striking that several countries could not provide data for all three indicators. Amongst those countries with complete data, Burkino Faso had the highest overall measurement at 89% and Ghana had the lowest at 55%.
Table 1: Measurement of comprehensiveness by the PHCPI in ‘trail-blazer’ countries of sub-Saharan Africa
| South Africa | Tanzania | Mozambique | Rwanda | Senegal | Kenya | Ghana | Cote d’Ivoire | Burkino Faso | Total | |
| Average availability of HIV and TB services | NA | 71 | 83 | 99 | 76 | NA | 65 | 54 | 93 | 77 |
| Average availability of tracer non-communicable disease diagnosis and management | 97 | 59 | 45 | NA | 77 | NA | 6 | 38 | 84 | 58 |
| Average availability of RMNCH services | 99 | 86 | 92 | 10 | 82 | NA | 94 | 84 | 90 | 80 |
| Total | – | 72 | 73 | – | 78 | – | 55 | 59 | 89 | 98 |
NA = not available
The Primary Care Assessment Tool (PCAT) also measures comprehensiveness of primary care across a much broader range of services (Box 1) from the perspective of patients, managers and primary care providers. The PCAT measures comprehensiveness on a scale from 1 to 4, where a score of 3 or more suggests good comprehensiveness. PCAT has been used to measure comprehensiveness in a national survey in South Africa1, three districts in Malawi2 and a set of private sector primary care clinics in Kenya (personal communication Dr Gulnaz Mohamoud). The mean scores for comprehensiveness were 3.2 in South Africa, 2.3 in Malawi and 2.1 in Kenya (personal communication Dr Gulnaz Mahmoud). Interestingly the worst score in this series was for private sector primary care and this may reflect the dominance of hospital-based services, easy access to specialists through health insurance and lack of any gatekeeping function. In Malawi primary care provided in primary hospitals was more comprehensive than care provided in health centres. In South Africa the scores of the managers and providers were significantly higher than that of patients at 3.6 (p<0.001) suggesting that either patients were unaware of the services available or that staff are overly optimistic. Nevertheless, only South Africa appeared to have an acceptable comprehensiveness score, although even there 33% of patients scored comprehensiveness as inadequate.
Comprehensiveness of primary care, therefore, is still a challenge in sub-Saharan Africa and needs to be addressed. One needs to interrogate whether the lack of comprehensiveness is embedded in policy and system design, related to key inputs such as composition of the primary health care teams, equipment and supplies, or to the capability and motivation of primary care providers.
Box 1: Services included in assessment of comprehensiveness by PCAT
Immunisations
Help with social grants
Dental care
Family planning
Counselling for alcohol, smoking, mental health, HIV,
TB testing
Suturing of lacerations
Tests for hearing and eyesight
Application of plaster cast
Cervical cancer screening
Anorectal examination for colon cancer
Antenatal care
Minor surgery for ingrowing toenail
Services for elderly and frail
- Bresick G, Von Pressentin KB, Mash R. Evaluating the performance of South African primary care: a cross-sectional descriptive survey. South African Family Practice. 2019 May 4;61(3):109-16.
- Dullie L, Meland E, Hetlevik Ø, et al. Performance of primary care in different healthcare facilities: a cross-sectional study of patients’ experiences in Southern Malawi. BMJ Open 2019;9:e029579. doi:10.1136/ bmjopen-2019-029579
