The current state
Barriers to facilitating research capacity building include the PHC service infrastructure, which needs to collect data in a way that allows input to research, as well as having strong local academic partners to play pivotal roles in hosting and conducting studies. Involvement with overseas contacts and training risks the emigration of skilled individuals from the LMIC workforce. This ‘brain drain’ is often considered in the context of LMIC to HIC emigration, but also exists from rural to urban, generalist PC provider to a more specialised one, and between countries on the same continent; each is hazardous, as skilled individuals are vital in LMICs to build capacity at the local level. Funding bias towards bioscience and laboratory-based research may threaten what and/or how PC research is conducted. Adding to this systematic funding bias is the limited number of research grants that explicitly allow capacity building.
Mainstream academic priorities do not necessarily reflect the needs of communities. In resourced contexts, there may be an increasing divide between researchers and practitioners because of evolving funding landscapes—researchers must devote more and more time to pure research to compete, making them less available to practice settings. In low-resource contexts, too often the issue is a lack of proper needs assessment and community engagement. Furthermore, HIC priorities or frameworks are not always relevant to LMIC. A current example is the COVID-19 pandemic, which HICs with poorly coordinated PC systems are having trouble navigating, for reasons very different from LMIC with lack of basic resources or access to care.
Examples: understanding the landscape
Guyana
Family medicine is a new specialty in Guyana, its inaugural class graduating in 2018. At present these family doctors, along with support of senior faculty from the University of Ottawa, are responsible for the daily operations of the Family Medicine Programme. Developing research has been challenging. Initially, a local mentorship structure was not in place for fostering research, and different visiting clinical faculty from HIC would review work done by residents and give conflicting feedback. Other challenges were young faculty not being very experienced in research writing; little time to dedicate to research because of the demands of clinical practice; poor access to statistical software and statisticians; and lack of funding.
To overcome these challenges, layers of supervision were established to facilitate the successful completion of research projects. Each resident was assigned research buddy and supervisors, and all projects reviewed by both the Family Medicine Programme in Ottawa and by a local committee.
Didactic sessions on how to develop a research question and methods were incorporated into the curriculum. The programme has formed a relationship with the Caribbean College of Family Physicians, which has a mandate to foster research. Collaborations with the Institute of Health Science Education, the Georgetown Public Hospital Corporation and the Academics Without Borders (AWB) aimed to start train-the-trainer research skills workshops for programme directors and faculty. AWB espouses a micro-research paradigm that permits residents to ‘work at their level’ and pursue projects that answer a meaningful research question that can be answered in the time they have available.
Through these partnerships, graduating family medicine residents have had the opportunity to present their research projects at national medical research conferences and publish their work.
Primafamed
In sub-Saharan Africa, the Primafamed network was established with funding from the Belgian government, incorporated 40 institutional members from 25 countries in the region, and stimulated regional inter-LMIC collaboration. It has supported the development of family medicine master’s programmes with a PC research component, while encouraging a community-oriented PC philosophy. Through the programme, HIC PC academics contribute their expertise, but LMIC PC academics determine the actual content. Primafamed’s annual meetings include workshops on research methodology and scientific writing, as well as opportunities to present and collaborate on research projects. The African Journal of Primary Health Care and Family Medicine, established in 2008, provides a supplement on PC research methods and a venue for emerging researchers to publish. There are attempts to grow doctoral programmes to reach a critical mass of researchers and improve supervision. In South Africa, a new practice-based research network, supported by Stellenbosch University, identifies research questions and conducts research relevant to the communities they serve.12 The University also supported Primafamed’s participation in the establishment of a new global PHC Research Consortium, which has the potential to access funding, collaborate across countries, address higher level questions and build research capacity.
However, the situation remains challenging. Most universities in the region are conservative, favouring bioscientific research; they are slow to embrace new innovative and qualitative methodologies, and obtaining ethics approval for proposals can be protracted.13 There are few established academic PC research centres, insufficient qualified supervisors and limited funding. More international support, through external supervisors and mentors, and collaborative funded projects, would be helpful.
Afriwon research collaborative
Afriwon, the young African family doctors group in WONCA (the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians), has developed a research training and mentorship pilot programme for African family doctors, which seeks to build research capacity through an innovative online learning programme. The curriculum is supported by the book ‘How to Do Primary Care Research’13 and involves an online course of 10 stepped modules (voice-over PowerPoints, podcasts) delivered over 4 months with regular web-based meetings and social media communications. Assessment is formative. Considerable mentorship is provided to each student from local researchers (not necessarily PC) and volunteer family physicians from sub-Saharan Africa, Europe and USA. After the formal programme concludes, regular research ‘Work in Progress’ meetings are held over the next year with ongoing e-mentorship and connection via social media platforms. The importance of maintaining connections with local collaborators is stressed.
Nigeria
Nigeria, now a middle-income country, began its national 4-year general practice/family medicine training programme in 1979.14 The programme includes a research dissertation period of 3–6 months to build the research capacity of future family physicians. However, most training centres are hospital-based rather than university-based, with poor incentives for PC research following postgraduate training. This limits pursuit of high-quality research and discourages efforts to build translational research skills necessary to improve PC delivery and services.
Over the years, establishment of academic family medicine departments in the universities has increased, with improvement in quality PC research. Since 1998, the Society of Family Physicians of Nigeria has been building the research capacity of family physicians through continuing medical education sessions at its annual scientific meetings, in addition to establishing the Nigerian Journal of Family Practice to disseminate research findings. In 2014, the Society established a practice-based research network involving collaboration of 76 family physician training centres. The network continues to build research capacity of family physicians and their trainees; however, there is need for incountry PhD-level training to boost research capacity.
PC research is hampered by poor funding, poor incentives, weak infrastructure, low quality of studies, low levels of international collaboration and poor knowledge translation into PC practice and policy. Addressing these challenges through innovative collaboration, enhanced funding and robust mentorship is necessary for improved PC delivery.
Malaysia
Malaysia, an upper-middle-income country, has developed considerable research capacity over the past two decades. The main stakeholder is the Ministry of Health, which has invested in PC research. Priority areas for PC were identified. Malaysia has introduced a family medicine master’s programme with research theses and is growing its doctoral programme. Initially PhDs were undertaken in developed countries, but now there is sufficient supervision to do these in Malaysian universities. PC research is housed in one of the six health and research institutes formed by the government. They have established a clinical research unit, with clinical trials now being conducted in PC as well as hospital settings. An Academy of Family Medicine and a Malaysian Primary Care Research Group have been set up, with research funding provided by the government.
It is seen as important to maintain close connections with other countries, especially HIC, for ongoing support in training, mentorship and knowledge transfer. The focus remains on research priorities with relevant and useful implementation studies.