Blog: Young Leaders Network

Reflection on a year of leadership

Young primary health care professionals are key to delivering the bold vision of Astana. The PHC Young Leaders Network is a community of early-career PHC professionals from across the world who are passionate about advocating for primary health care.

UHC cannot be attained unless young voices - especially of those who are on the frontlines of primary health care delivery - are included in the conversation. The young voices of today will be the leaders of tomorrow in achieving UHC via PHC..

The WHO PHC Young Leaders Network (YLN) is a group of 21 young professionals from diverse backgrounds and includes doctors, nurses, midwives, social workers, epidemiologists, academics, researchers, public health experts, and health economists.

As a group officially convened by WHO, the we were afforded a platform for our collective voice, and we became a community that offered a venue for sharing and learning and for nurturing each one of us. There has been a diffusion of ideas and skills, particularly on best practices in managing the delivery of primary health care services, the PHC research agenda, and ways to strengthen the health system.

The YLN’s inaugural activity was participating in the Global Conference on PHC in Astana, Kazakhstan in October 2018. In May 2019, the YLN then attended the 72nd World Health Assembly in Geneva, Switzerland. At the WHA we presented on our shared experiences of PHC in academia as well as in conflict-affected areas. YLN representatives also attended the 74th UN General Assembly in October 2019 and contributed during the side event on PHC towards UHC.

Through the year, we have participated in monthly webinars which provided the opportunity to share each individual’s inspirational work going on at both local and regional levels. We also received mentorship from experts in PHC.

Collaboration between the members of the YLN has allowed us to understand the breadth of PHC and gain some insight into the challenges of each other’s contexts, whether resource-limited settings, conflict areas or developed countries. The visibility that the network has given members has also helped us advocate for the importance of PHC, including to fellow health professionals.

Finally, exposure to the global health scene has made us more aware of the work that needs to be done, and strengthened our resolve to focus on our specific areas of practice. We believe that it is impossible to achieve UHC and improve the quality of PHC without knowing the needs of youth.

Young people are capable of bringing their perspectives and their expertise and of building effective partnerships with senior public health organizations for shared-decision making. We urge health professionals to seek youth engagement in the development and implementation of PHC-related reforms and policies at all levels. It has been a privilege to be part of the YLN in the past year.

Palliative care delivery in Sri Lanka: a GP’s perspective

As a GP in Sri Lanka, I have a particular interest in palliative care, providing outpatient care as well as home visits when deemed necessary. Family doctors, because they are integrated into the community, are the health professionals most familiar with the care needs, resources, community dynamics and cultural sensitivities of the patients and communities they serve. Thus they are in a unique position to provide effective, patient-centred palliative care.

What is palliative care? It is an approach that aims to improve the quality of life of both patients and their families with regards to the physical, psychosocial and spiritual problems associated with life-threatening illnesses. The uniqueness of the discipline of palliative care lies in its holistic approach to care and its emphasis on respecting clinical ethics. Palliative care is part of primary health care, alongside preventive, promotive, curative and rehabilitative health care services.

In Sri Lanka, palliative care is in its infancy. One of our recent studies[1] that sought to identify pain management practices in oncology hospitals revealed that many physicians in Sri Lanka do not carry out adequate pain assessment of terminally ill patients, leading to suboptimal management of pain. It also showed that there was a general lack of experience with, and engagement in, pain assessment and palliative care. When asked, the consultant oncologist of the said tertiary care hospital expressed that his team was poorly trained to provide “quality of life”-oriented care and are unfamiliar with the concept of clinical auditing.

This lack of knowledge around palliative care is not unique to Sri Lanka. A systematic review of international literature on teaching and learning in palliative care within medical undergraduate curricula pointed out a lack of consistency and fragmentation of teaching in the discipline and stressed the importance of devising an integrated curriculum with a strong emphasis on a multidisciplinary approach.

To gauge the level of knowledge among young medical graduates in Sri Lanka, we carried out a survey[2] of pre-residency medical graduates through a social media-based online tool. The results showed that only 22% of students were familiar with the concept of palliative care, and 76% of respondents felt that they had inadequate knowledge to manage symptoms in a dying patient. In short, medical school graduates in Sri Lanka lack knowledge of the clinical, organizational, and ethical imperatives involved in caring for dying patients.

As a general practitioner whose primary clinical and academic interests lie in palliative care, I do, however, see some signs of progress. In 2018, the Postgraduate Institute of Medicine at the University of Colombo developed a diploma course in palliative medicine for medical doctors. Currently I am working to incorporate palliative care in the undergraduate family medicine curriculum at the University of Sri Jayewardenepura, where I have been a lecturer in the Department of Family Medicine since 2015.

The demand for palliative care services is increasing, a result of the growing elderly population. And 48% of the students surveyed above felt that all dying patients should receive palliative care, indicating a growing awareness of the discipline. There remains much work to do – but I am hopeful that we can continue to progress towards a highly developed, patient-centred approach to palliative care in the years to come.

Bio:

Dr Chamath Fernando is a General Practitioner employed as a lecturer at the University of Sri Jayewardenepura, Sri Lanka. He serves as the Coordinator and Palliative Care Lead for the National Centre for Primary Care and Allergy Research. He is also a PhD candidate in palliative care at the University of Lancaster in the UK.

• MBBS, DFM (Sri Lanka), DipPallMed (UK), MRCGP [INT]
• Fellow in PhD - Palliative Care (UK)

References:

Lessons in PHC from the Alaska Tribal Health System

Rural Alaska is home to one of the most innovative primary health care (PHC) systems in the world. As a health worker within the Alaska Tribal Health System and faculty member at Harvard Medical School, I spend a lot of time trying to understand how and why this system excels, and what lessons can be drawn to support the strengthening of PHC across the world.

Building care systems around local context, culture, and values

Rural Alaska is a vast, isolated, and largely road less region that poses a range of geographic, economic, and human resource challenges to the delivery of essential health services. In addition, the recent colonial history and ongoing structural violence perpetrated against rural Alaska Natives place individuals, families, and communities at elevated risk for adverse health outcomes. In response, the Alaska Tribal Health System was developed to administer health services under tribal governance through compacts with the United States Indian Health Service. This model relies on networks of village-based community health workers, physicians and other health professionals at regional hub hospitals, and a large tertiary care center in Anchorage to deliver a wide range of health services. 

The majority of primary care services in rural and remote Alaska Native villages are delivered by trained local health workers called Community Health Aides or, at the highest level, Community Health Practitioners. This community health worker program has roots in a novel partnership between traveling public health nurses and local Alaska Native volunteers during a 1950s tuberculosis epidemic, following a failed policy of forced relocation to southern tuberculosis sanitoria. By bringing care to communities through directly observed therapy, as opposed to displacing patients at the cost of public trust, the program garnered significant community and government support. In 1968, federal funding made the Community Health Aide Program a sustainable reality for rural Alaska Native communities. Today, Community Health Aides/Practitioners serve as the front lines of rural Alaska primary care, with an estimated quarter million annual clinical encounters across 180 rural Alaska villages.

(”Primary health care” is an overall approach which encompasses the three aspects of: multisectoral policy and action to address the broader determinants of health; empowering individuals, families and communities; and meeting people’s essential health needs throughout their lives. “Primary care” is a subset of PHC and refers to essential, first-contact care provided in a community setting.)

Integrating technology and community-based care

Health communications technologies played a pivotal role in the expansion and improvement of PHC under the Alaska Tribal Health System. Throughout the 1960s, the United States National Aeronautics and Space Administration (NASA) pioneered the use of satellite technology to connect rural villages to physicians in hub communities. Physician-to-community health worker communication became the basis for the federal authorization and expansion of the Community Health Aide Program in 1968, with efforts significantly bolstered over time by evolving satellite technology, increased government investment in rural U.S. communications infrastructure, and the embrace of health-promoting communications tools in village communities. As these programs scaled and evolved between 1950 and 1980, life expectancy for Alaska Natives grew by 20 years. Today, Internet-facilitated telemedicine – CHA/Ps, regional providers, and specialists at tertiary care centers – has become the backbone of rural Alaska PHC.

Operationalizing social medicine

Social medicine involves building care systems that address not only biological sources of disease but also the social, political, and economic drivers of health. At its best, social medicine incorporates aspects of social science, political economy, public health, and clinical medicine into a moral tradition that sees social and health inequities as twin phenomena, and which drives action to address both.

The Alaska Tribal Health System operationalizes social medicine through the federal guarantee of essential health services to Alaska Native beneficiaries and the horizontal integration of tribal government, health, and social services to address the social determinants of health. In this model, nonprofit health corporations, funded by the federal government and led by regional Alaska Native boards elected through local tribal governments, assume responsibility for the delivery of a wide breadth of services, from traditional primary care to housing, food, health education, and public safety programs. Health services are without cost for Alaska Native beneficiaries as a result of trust and treaty agreements with the United States government. Thus, many barriers to care are reduced or removed through a publicly-funded, tribally-administered, and integrated care system—with primary care at its center.

Beyond these structural features, my work in the Alaska Tribal Health System involves translating social medicine into a practical clinical skill. This means that primary care workers receive clinical mentorship, demonstrate competency, and advance patient and population health through social medicine skills, including a focus on addressing the social determinants of health, developing advocacy tools, and designing clinical innovations to reduce inequities in the health and care of our patients and communities. Within a broader ethics of decoloniality and social care, this framework is intended to advance an Alaska Native health equity agenda through coordinated, community-based action to address the social determinants of health.

The integration of multisectoral policy and action on the social determinants of health with an engaged and empowered community and primary care services makes this a good example of primary health care

Relevance to global PHC

I see each of these principles as generally relevant to building strong PHC systems. First, investment in robust community health worker programs is of paramount importance. Second, such programs can be bolstered and expanded through health communications technologies. Third, social medicine can be translated from academic tradition to operational and clinical skill to address the key social drivers of health.

PHC educators play a central role in cultivating a practical and just vision for global PHC with an actionable equity plan at its center. Those of us privileged to train the next generation of PHC leaders would be well-served to focus our efforts on developing health workforces responsive to local contexts, cultures, and needs; leveraging technology to improve care access and quality; and operationalizing social medicine in global health policy, systems, and care delivery.

Social medicine is a key element and an eloquent example of primary health care in action.

Bio:

Lucas Trout is managing partner of Maniilaq Social Medicine and lecturer on global health and social medicine at Harvard Medical School. His works centers on primary care education and health system strengthening in rural Alaska Native communities, with a particular focus on leveraging academic and tribal government partnerships to address the social determinants of health. Lucas plans on dedicating his career to ensuring equitable access to quality, comprehensive, and culturally safe primary care to realize the right to health across the rural American North and West.

Digital health solutions: technology in primary health care

As a primary health care doctor I use digital technology in my practice daily. Technology has been galloping forward, developing at an astonishing rate in the past few years. New possibilities keep appearing at an incredible rate.

I use electronic health records to keep track of information on the patients I follow in my practice. I also use an e-referral system when patients need to be assessed in a secondary care context. With patients, I use online platforms to help me in decision-making and use these platforms’ resources to promote patient education.

Patient education platforms guarantee a more equitable access to health care, as I am able to access and choose from a variety of resources, considering the patient I am working with. I can also prescribe apps for follow-up and to empower my patients in their health and disease management.

E-referral networks are another key tool. They make it easier for me to collaborate with other health care professionals, whether in primary, secondary or tertiary care. At the same time, I also have the possibility to draw collaborative strategies and to discuss action points, clinical cases and management with colleagues while keeping patient data safe. These possibilities increase exponentially with social media platforms, especially the ones designed for health care professionals.  

As for other technological solutions, I advise my patients to use technology such as wearables. Another tool that I also use in my practice is a social robot that helps with the symptom management of the patients I follow.

Digital technology facilitates the delivery of care and gives us the power to support our activities in primary health care. However, in caring for families longitudinally, it is important to remember that different generations of patients have different expectations regarding technology and health care. So I adapt my practice by offering solutions that fit both the elderly as well as millennials, who have grown up in a society that is already surrounded by technology.

These resources can be an important tool for primary health care and can help countries to achieve universal health coverage and the Sustainable Development Goals. This was one of the key points discussed at the Global Health Conference on Primary Health Care, held 25-26 October 2018 in Astana, Kazakhstan.

Bio:

Ana Nunes Barata is a family doctor in Amadora, Portugal. She has a MSc in hospice and palliative care and a postgraduate degree in geriatrics. At present, she holds the position of the Young Doctor Representative in WONCA's Executive Committee. In addition, she is a member of the executive group of the Portuguese Association of Family Medicine and coordinates the Department of Residents and Family Medicine Trainees. Ana is also a member of the WHO's PHC Young Leaders Network and the Youth Hub.

The World Health Assembly – a UK GP’s Perspective

Last week, I had the privilege of attending the World Health Assembly as part of the PHC Young Leaders Network. Although I was enthusiastic about the opportunity, I also felt hesitant. How useful could participating in an international conference be to a GP from the UK? As it turns out, I was to discover upon my return to the (immensely different) UK clinical setting, I did not feel dissociated – rather, I felt empowered.

A lot of the topics discussed at the World Health Assembly may have initially felt far removed from my work as a GP in the UK and could perhaps be perceived as futile, particularly from my perspective at as a frontline worker in a high-income country. How would what they were saying affect my patients and my practice in the UK? However, my siloed view of health was to be rightly challenged.

Last year, I – along with 20 other colleagues – was selected from over two thousand applicants from across the globe to be an inaugural member of the Young Leaders Network. We were chosen based on our achievements in the delivery of primary care.

We were first brought together at the Global Conference on Primary Health Care which took place in Astana, Kazakhstan in October 2018. We were then invited to attend the WHA in May. 

I had not attended the WHA before nor had I visited the WHO in Geneva. I had an overwhelming sense of awe (compounded with a dose of imposter syndrome) on just being in this prestigious institution– it was all very surreal.

But as an attendee at the WHA, I was not just visiting the building – I had the opportunity to observe the plenary sessions, committee meetings and side events during the week. 

The opening meeting took place in the famous Assembly Hall of the United Nations Palais. There was a high level of formality and a significant amount of politicking to just get an agreed agenda. However, as topics progressed, the consensus among participants on improving health and the desire to work collaboratively to tackle global challenges became evident.

To my surprise, the discussions were all relatable to the UK. Common challenges such as workforce issues, technology and air pollution were discussed. Global policy to address these topics guides national health strategies. It also aids collaborative learning and the establishment of essential partnerships that can help tackle some of these issues. I was especially gratified to see the importance placed on the integrative approach of PHC throughout the week.

Having a united vision, aims, and policies - even if we are far from achieving them – is hugely important. The WHA allows us to develop and agree these with a consensus from across the globe for our strategy in health.   

The side events were another valuable opportunity to learn more on key topics and practice across the globe. There was the opportunity throughout the WHA to network and explore the work of WHO and its partners. Meeting new people from across the globe on the numerous different health topics was insightful and there a great amount of reciprocal learning across our diverse backgrounds. I met individuals from working in vastly different settings who were able to assist my work in the UK at a local and national level. 

I also felt that myself and my fellow Young Leaders brought something to the WHA. As front-line clinicians, social workers/advocates, researchers and managers, we were able to share our experiences and advocate on behalf of the patient voice and emphasise the value of PHC. At a side event which we hosted, my PHC YLN colleagues and I presented and discussed two key issues. We spoke of workforce problems and of health care delivery in difficult settings, which, despite the diverse backgrounds of YLN members, we all shared.

My key reflection on the whole experience was the benefit of international collaboration - not just within the Young Leaders Network but also with all the delegates of the conference. It made me realize why events like the WHA and work of WHO are needed at the global level. And it makes me value even more the positive contribution that myself and my colleagues are making to the global ambition of PHC every day. 

Why primary health care nursing is coming up short

3 April 2019

Less than 25% of nursing students say they want to enter primary health care nursing, despite the fact that it is one of the fastest-growing areas of medicine. Kaara Calma examines the vital role perceptions and education have in preparing undergraduate nursing students for careers in PHC nursing.

The future of the primary health care nursing workforce

By Kaara Calma

My name is Kaara Ray B. Calma and I am a full-time PhD candidate, an academic in the School of Nursing at the University of Wollongong (UOW), Australia, and a registered nurse working in general practice. Since the day I earned my title as an RN, I have remained committed to increasing the visibility of the nursing workforce. Inspired by the work of many PHC nurses and researchers, and driven by the remaining systemic gaps in PHC, I decided to undertake research relating to the PHC nursing workforce.

In 2018, I started as a full time PhD candidate in the School of Nursing at UOW, for which I was awarded an Australian Government Research Training Scholarship. My project now explores final-year undergraduate nursing students’ preparedness to work in general practice following graduation. One main driver for this was the knowledge that the PHC sector has experienced growing demand, a result of the expansion in chronic disease burdens and an aging population ^{(1, 2, 3)}. Although we know that the role of nurses in PHC settings is increasingly valued ⁽⁴⁾, research to date has focussed on strategies to preserve the existing PHC nursing workforce⁽⁵⁾, employment conditions of PHC nurses⁽⁶⁾, and transitioning from acute care to PHC^{(7) (8, 9)}. There remains a knowledge gap concerning how pre-registration nursing students are prepared for employment in PHC following graduation.

To address this, my PhD project aims to explore final-year undergraduate nursing students’ preparedness to work in general practice following graduation. The first stage of this project was a literature review to examine how undergraduate curricula influence nursing students’ perceptions of and preparedness to work in PHC settings (paper under review). Three themes were identified, namely curriculum, knowledge and attitudes, and career intention.

Universities face barriers in delivering PHC content. These include limited numbers of PHC trained academics^{(10, 11)}, insufficiency of PHC clinical placements^{(10, 11, 12)}, and students’ expectations of learning acute care nursing^{(11, 12, 13)}. Another barrier is a pervasive belief that undergraduate nursing programs should prepare students to work in hospitals, which leads universities to deliver acute care content in the undergraduate coursework⁽¹¹⁾. Consequently, many undergraduate nursing curricula remain acute-care centric^{(10, 14)}, where PHC is often only just embedded within broader health units⁽¹⁵⁾.

Due to the inconsistencies in undergraduate curricula, some nursing students have developed negative perceptions of PHC, considering PHC as a limiting pathway in terms of career advancement^{(11, 16)} and as a job more suited for older, experienced nurses^{(17, 18)}. These perceptions evidently influence nursing students’ intentions to work in PHC, with at least two studies reporting that less than a quarter of nursing students express a desire to work in this setting^{(17, 19)}.

Read Kaara Calma’s perspective on the Young Leaders Network (with permission from Primary Times, the magazine of the Australian Primary Health Care Nurses Association

PrimaryTimesWinter2019

With thanks to Professor Elizabeth Halcomb & Dr. Moira Stephens, my co-authors in the literature review article submitted for review in an international journal

Bio:

Kaara Ray B. Calma is a registered nurse and authorized nurse immunizer who has been working in general practice since 2016. Kaara’s thesis project, 'An exploration of the experiences of Australian Grey Nomads traveling with chronic conditions', was published in the Australian Journal of Primary Health. Currently in the second year of her PhD studies, Kaara teaches primary health care at UOW within the Bachelor of Nursing course and has actively engaged in the conceptualization of the primary health care subject. Kaara also represented Australia at the Global Conference on Primary Health Care in Astana, Kazakhstan in October 2018 as a member of the Primary Health Care Young Leaders Network.

References:

1. Peters, K., McInnes, S., and Halcomb, E., Nursing students’ experiences of clinical placement in community settings: A qualitative study, Collegian, 2015, 22: p. 175-181.
2. Murray-Parahi, P., DiGiacomo, M., Jackson, D., and Davidson, P.M., New graduate registered nurse transition into primary health care roles: an integrative literature review, Journal of Clinical Nursing, 2016, 25(21/22): p. 3084-3101.
3. Erler, A., Bodenheimer, T., Baker, R., Goodwin, N., Spreeuwenberg, C., Vrijhoef, H.J.M., Nolte, E., and Gerlach, F.M., Preparing primary care for the future - perspectives from the Netherlands, England, and USA, Zeitschrift Fur Evidenz, Fortbildung Und Qualitat Im Gesundheitswesen, 2011, 105(8): p. 571-580.
4. Martínez-González, N.A., Tandjung, R., Djalali, S., and Rosemann, T., The impact of physician–nurse task shifting in primary care on the course of disease: a systematic review, Human Resources for Health, 2015, 13(1): p. 1-14.
5. Gordon, C.J., Aggar, C., Williams, A.M., Walker, L., Willcock, S.M., and Bloomfield, J., A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce?, BMC Nursing, 2014, 13(1): p. 1-13.
6. Halcomb, E., Ashley, C., James, S., and Smyth, E., Employment conditions of Australian primary health care nurses, Collegian, 2018, 25(1): p. 65-71.
7. Ashley, C., Halcomb, E., Peters, K., and Brown, A., Exploring why nurses transition from acute care to primary health care employment, Applied Nursing Research, 2017, 38: p. 83-87.
8. Ashley, C., Brown, A., Halcomb, E., and Peters, K., Registered nurses transitioning from acute care to primary healthcare employment: a qualitative insight into nurses’ experiences, Journal of Clinical Nursing, 2018a, 27(3/4): p. 661-668.
9. Ashley, C., Halcomb, E., Brown, A., and Peters, K., Experiences of registered nurses transitioning from employment in acute care to primary health care-quantitative findings from a mixed-methods study, Journal of Clinical Nursing, 2018b, 27(1/2): p. 355-362.
10. Albutt, G., Ali, P., and Watson, R., Preparing nurses to work in primary care: educators' perspectives, Nursing Standard, 2013, 27(36): p. 41-46.
11. Wojnar, D.M. and Whelan, E.M., Preparing nursing students for enhanced roles in primary care: The current state of prelicensure and RN-to-BSN education, Nursing Outlook, 2017, 65(2): p. 222-232.
12. Betony, K. and Yarwood, J., What exposure do student nurses have to primary health care and community nursing during the New Zealand undergraduate Bachelor of Nursing programme?, Nurse Education Today, 2013, 33(10): p. 1136-1142.
13. Cooper, S., Cant, R., Browning, M., and Robinson, E., Preparing nursing students for the future: development and implementation of an Australian Bachelor of Nursing programme with a community health focus, Contemporary Nurse, 2014, 49: p. 68-74.
14. Ali, P.A., Watson, R., and Albutt, G., Are English novice nurses prepared to work in primary care setting?, Nurse Education in Practice, 2011, 11: p. 304-308.
15. Keleher, H., Parker, R., and Francis, K., Preparing nurses for primary health care futures: how well do Australian nursing courses perform?, Australian Journal of Primary Health, 2010, 16(3): p. 211-216.
16. van Iersel, M., Latour, C.H.M., de Vos, R., Kirschner, P.A., and Scholte op Reimer, W.J.M., Perceptions of community care and placement preferences in first-year nursing students: A multicentre, cross-sectional study, Nurse Education Today, 2018a, 60: p. 92-97.
17. Bloomfield, J.G., Gordon, C.J., Williams, A.M., and Aggar, C., Nursing students’ intentions to enter primary health care as a career option: findings from a national survey, Collegian, 2015, 22(2): p. 161-167.
18. Duah, M.A., Baccalaureate nursing students’ perceptions of community health nursing as a career, in Faculty of Graduate and Postdoctoral Studies. 2015, University of Ottawa: Ottawa. p. 275-288.
19. Bloomfield, J.G., Aggar, C., Thomas, T.H.T., and Gordon, C.J., Factors associated with final year nursing students' desire to work in the primary health care setting: findings from a national cross-sectional survey, Nurse Education Today, 2018, 61: p. 9-14.