Primary care research--an international responsibility

The provision of primary care secures equitable and cost-effective health care.1,2 Academic primary care is strong in countries where substantial levels of research funding are available3 with quality outputs achieved.4 Despite this, many high- and low-income countries do not have a comprehensive primary health care system, much less one built on scientific evidence. A recent report called for worldwide efforts to increase primary care-based evidence to inform practice.5 Primary care faces diverse challenges, including financial constraints, political whim, unstable natural environments, threats from new infectious diseases and changing population demographics including aging, more diversity as a result of migration and increased rates of dementia, multi-morbidity and obesity.5 These are worldwide challenges, although national strategies to manage them differ. Even though the unfairness of uneven distribution of wealth and health across the globe has long been acknowledged, it has been treated as a local problem in low-income countries. An emphasis on foreign aid, and accordingly the setup of foreign vertical health care systems, has disturbed the development of many local health care systems.6 An emerging view is that the huge health problems in low-income countries are not only local issues or a question of unfairness. With increased globalization, the gross inequity in health affects us all and is a threat to global stability. Additionally, many of today's challenges are shared by primary care providers globally. This creates a new willingness to address global health issues in a comprehensive perspective,7 which fits in well with the perspective of primary care. However, primary care research has been accused of being ‘navel-gazing’ and of limited clinical importance.8,9 More international collaboration is called for and should involve researchers in low-income settings.10 Primary care research and academic capacity building in both low-income and high-income countries are needed to support and sustain this process. In this context, we find it both surprising and worrying that the World Health Organization does not include research and academic capacity building in their five key elements to achieve the goal of better health for all through delivery of primary care.11 What can primary care researchers do to improve health in a global perspective? Below, we offer five examples of where we believe researchers can contribute. The examples are not exhaustive but rather are intended by us to inspire further discussion about the potential for primary care research to support the development of better health for all, including equity in health and health care delivery. Firstly, if the research is to continue to be relevant, generalizable and of high quality, all patients should have the opportunity to participate in research, requiring investment in research infrastructure to prevent selective recruitment. This will maximize the population and context relevance in combination with innovative multidisciplinary approaches to study design that guarantee internal and external validity. All stakeholders should be able to influence the research agenda, for example, by working with organizations such as the James Lind Alliance.12 We support organizations like the National Institute for Health Research (NIHR) Health Technology Assessment which increasingly adopt such approaches, complemented by open calls allowing researchers to set some of the agenda. Secondly, we believe the primary care research community needs to respond more rapidly to changes in the global health care environment. For example, there is need for ‘real-time’ evidence to underpin the effects of health care reforms and respond to the threat of new and emerging infectious diseases with potential widespread health and economic impact, as illustrated by the recent H1N1 pandemic and the July 2011 Escherichia coli outbreak in Germany. In both cases, this research can only be conducted when contemporaneous data are collated and analysed with proportionate and timely ethical and governance approvals in place. The European Union could lead global efforts by supporting an effective infrastructure for the collection of standardized primary care data across health care systems and countries. Thirdly, we need to better understand how environment, population and individual risk factors influence the health of primary care patients. For example, greater phenotypic and genotypic characterization will allow more individualized targeting of tests and treatments to reduce uncertainty and maximize the likelihood that therapy will be given to the patient most likely to benefit. Furthermore, research should include the broadest possible perspective and include factors not often considered in life-course epidemiology, for example, the impact of adverse life circumstances such as domestic violence and lack of access to education on health. Fourthly, new technologies should increasingly influence the generation, conduct and dissemination of research. The role of mobile phones in recent Middle Eastern regime changes illustrates the power of information sharing. Moreover, there is potential to harness mobile phone technology in the collection of population-based data, especially among some traditionally hard to reach groups such as adolescents.13 Finally, the benefits of research for patient outcomes will only be realized through implementation. While resource and attention are being directed at the bench to bedside, or so-called ‘first translational gap’, bridging the ‘second translational gap’14 will require the use of complex and targeted interventions. This is particularly pertinent in the decentralized world of primary care delivery systems. Innovative multidisciplinary research approaches such as those outlined above should be recognized and encouraged by policy makers and funding bodies. Current primary care research leaders should engage more widely in political and social debate, prioritize global capacity development, support international research collaborations and develop future research leaders. Funding: no funding was received to support the writing of this manuscript. Ethical approval: none. Conflict of interest statement: none. Contributorship statement. This manuscript was drafted to reflect discussions between all members of the Senior Brisbane Initiative Cohort [all authors are part of the Oxford International Primary Care Research Leadership Programme (BI), Department of Primary Health Care Sciences, University of Oxford]. The first draft was written by ADH, GR and SP. All authors refined the first draft and approved the final version.