Reflective writing and keeping portfolios during rural hospital attachments has been shown to give medical students more confidence, better communication skills and clinical competence, thereby making them stronger adult learners. The role of supervisors as facilitators of learning during Community-based Education rural site visits is critical. The University of Zimbabwe Faculty of Medicine and Health Sciences established faculty development workshops to train supervisors to be better able to support students in becoming active learners and critical thinkers, giving them constructive feedback, and encouraging them to look for positive outcomes during their rural attachments. These educational skills were new to most supervisors, requiring a culture change from the usual didactic approaches. Educators had to learn about adult learning theories, the constructivist approach to knowledge creation, role-modelling and methods of assessment that were empowering for students. They were encouraged to form communities of practice through the faculty development process of training and assessment and to consider how to develop research and scholarship in documenting their experiences as facilitators and learning partners with their students and colleagues. These activities enhanced their professional identity formation as scholars, educators and facilitators. Their exposure to the functioning of rural hospitals, partly through narratives of the students’ reflective writing, enabled them to develop a greater appreciation of the potential of primary care and the district health services as the foundation of the Zimbabwe health system. Future benefits could include application of this training to other health professional programmes, as part of interprofessional education.

Women attending public and private sector health facilities in Africa have reported abuse and neglect during childbirth, which carries a risk of poor health outcomes. We explored from the midwives' perspective the influence of an educational intervention in changing the attitudes, behaviour and practices of a group of midwives in Zimbabwe, using transformative learning theory as the conceptual framework. The twelve-week educational intervention motivating for Respectful Maternity Care consisted of a two-day workshop and five follow-up sessions every two weeks. Thematic analysis was conducted on eighteen reflective journals written by the midwives with member-checking during follow-up discussions and a further one-day participative workshop a year later. The midwives reported being more women-centred, with involvement of birth companions and use of different labour positions, stronger professional pride and agency, collaborative decision-making and less hierarchical relationships which persisted over the year. Their journal narratives included examples of treating birthing women with more compassion. Some categories aligned with the phases of transformative learning theory (self-examination of prior experience, building of competence and self-confidence into new roles and relationships). Others related to improving communications and effective teamwork, providing role-models of good behaviour, use of scientific knowledge to inform practice and demonstrating competence in management of complex cases. This study shows that innovative educational initiatives have the potential to change the way midwives work together, even in challenging physical environments, leading to a shared vision for the quality of service they want to provide, to improve health outcomes and to develop life-long learning skills.

The health crises related to climate change in African countries are predicted to get worse and more prevalent. The response to catastrophic events such as cyclones, flooding and landslides must be rapid and well-coordinated. Slower adverse events such as droughts, heat stress and food insecurity must similarly be anticipated, planned for and resourced. There are lessons to be learnt by the health system following the crisis created by Cyclone Idai in Zimbabwe during March 2019, which required a massive humanitarian response to mitigate the impact of torrential rainfall on lives and livelihoods. Several researchers and organisations documented the emergency response in detail. They reported that the government response was hampered by a lack of preparedness, poor planning, inadequate resource mobilisation and weak coordination. Rural communities did not access the early warning cyclone alerts disseminated through television, print and social media, nor did they appreciate the seriousness of events until it was too late. Primary health care (PHC) teams are familiar and trusted by the communities they serve and have a critical role in raising public awareness and in documenting the evolving impact of climate change, using established health indicators and local narratives. PHC leaders and providers have the knowledge and skills to mediate between government bodies, international agencies, other stakeholders and communities on the predicted impact of climate change on health outcomes, highlighting the vulnerability of disadvantaged and impoverished groups. They are also able to work with community leaders, using indigenous knowledge on weather patterns, to build local engagement in protection plans. Contribution: This article describes the role health professionals and civil society can play in educating the public on the dangers faced in the near future as a result of climate change and actions that can be taken to become more resilient and to mitigate this impact.

Family Medicine training in Africa is constrained by limited postgraduate educational resources and opportunities. Specialist training programmes in surgery, anaesthetics, internal medicine, paediatrics and others have developed a range of trainers and assessors through colleges across East, Central and Southern Africa (ECSA). Each college has a single curriculum with standardised training and assessment in designated institutions, which run alongside and in collaboration with the Master's in Medicine programmes in universities. Partnerships between colleges in Britain, Ireland and Canada and national specialist associations have led to joint training-of-trainer courses, e-learning platforms, improved regional coordination, better educational networking and research opportunities through regional conferences and joint publications. We propose the establishment of a regional college for specialist training of family physicians, similar to other specialist colleges in ECSA. Partnerships with family medicine programmes in South Africa, Canada and Australia, with support from international institutions such as the Primary Care and Family Medicine Network for Sub-Saharan Africa (PRIMAFAMED) and the World Organisation of Family Doctors (WONCA Africa), would be essential for its success. Improved health outcomes have been demonstrated with strong primary care systems and related to the number of family physicians in communities. A single regional college would make better use of resources available for training, assessment and accreditation and strengthen international and regional partnerships. Family medicine training in Africa could benefit from the experience of specialist colleges in the ECSA region to accelerate training of a critical mass of family physicians. This will raise the profile of family medicine in Africa and contribute to improved quality of primary care and clinical services in district hospitals.

Background: In May 2020, the African Journal of Primary Health Care and Family Medicine invited submissions on lessons learnt from responses to the COVID-19 pandemic from primary care providers in Africa. This included descriptions of innovations and good practices, the management of COVID-19 in district health services and responses of communities to the outbreak. Aim: To synthesise the lessons learnt from the COVID-19 pandemic in the Africa region. Methods: A thematic document analysis was conducted on twenty-seven short report publications from Botswana, Ghana, Nigeria, South Africa, Uganda and Zimbabwe. Findings: Eight major themes were derived from the data: community-based activities; screening and testing; reorganisation of health services; emergency care for COVID-19; maintenance of essential non-COVID-19 health services; caring for the vulnerable; use of information technology; and reframing training opportunities. Community health workers were a vital community resource, delivering medications and other supplies to homes, as well as following up on patients with chronic conditions. More investment in community partnerships and social mobilisation was proposed. Difficulties with procurement of test kits and turn-around times were constraints for most countries. Authors described how services were reorganised for focused COVID-19 activities, sometimes to the detriment of essential services and training of junior doctors. Innovations in use of internet technology for communication and remote consultations were explored. The contribution of family medicine principles in upholding the humanity of patients and their families, clear leadership and planning, multidisciplinary teamwork and continuity of care was emphasised even in the context of providing critical care. Conclusions: The community-orientated primary care approach was emphasised as well as long-term benefits of technological innovations. The pandemic exposed the need to deliver on governmental commitments to strengthening primary health care and universal health coverage.

Although family physicians (FPs) are community-oriented primary care generalists and should be the entry point for the population's interaction with the health system, they are underrepresented in research on the climate change, migration, and health(care) nexus (hereafter referred to as the nexus). Similarly, FPs can provide valuable insights into building capacity through integrating health-determining sectors for climate-resilient and migration-inclusive health systems, especially in Sub-Saharan Africa (SSA). Here, we explore FPs' perceptions on the nexus in SSA and on intersectoral capacity building. Three focus groups conducted during the 2019 WONCA-Africa conference in Uganda were transcribed verbatim and analyzed using an inductive thematic approach. Participants' perceived interactions related to (1) migration and climate change, (2) migration for better health and healthcare, (3) health impacts of climate change and the role of healthcare, and (4) health impacts of migration and the role of healthcare were studied. We coined these complex and reinforcing interactions as continuous feedback loops intertwined with socio-economic, institutional, and demographic context. Participants identified five intersectoral capacity-building opportunities on micro, meso, macro, and supra (international) levels: multi-dimensional and multi-layered governance structures; improving FP training and primary healthcare working conditions; health advocacy in primary healthcare; collaboration between the health sector and civil society; and more responsibilities for high-income countries. This exploratory study presents a unique and novel perspective on the nexus in SSA which contributes to interdisciplinary research agendas and FP policy responses on national, regional, and global levels.

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs’ work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care.

The African Journal of Primary Health & Family Medicine welcomes submissions that encourage scholarly exchange between family medicine and primary health care researchers and practitioners across Africa and the developing world, whilst providing a contextual and holistic view of family medicine as practiced across the continent.

The international community increasingly acknowledges that climate change is not only spurring environmental degradation and health deterioration,1 it is also an important direct and indirect driver of migration, conflict, and human rights violations. This is particularly true for Sub-Saharan Africa (SSA), the region where people — in contrast to high-income countries and high energy consuming industries, which emit the most greenhouse gasses on a global scale — are relatively more vulnerable to climate change, because their precarious socioeconomic status, lack of resources, and weak health systems constrain their adaptation capacity.2 Still, debate and research on the explicit interactions between climate change, migration, and health are scarce, and prevailing research and policies disproportionally neglect the voice of the global South, such as that of SSA. During the African conference of the World Organisation of Family Doctors (WONCA) and the African Primary Care and Family Medicine Education Network (Primafamed) meeting in Kampala, Uganda (4–6, June 2019), we organised focus groups with primary health care experts and family physicians (FPs) from twelve SSA countries, to explore these interactions. Although the climate research community underrepresents FPs, the latter are excellent sources of information. Their position in the centre of the community gives them insight …

Introduction Community-orientated primary care (COPC) is an approach to primary healthcare (PHC) that originated in South Africa and contributed to the formulation of the Declaration of Alma-Ata 40 years ago. Despite this, PHC remains poorly developed in sub-Saharan African countries. There has been a resurgence of interest in strengthening PHC systems in the last few years and identifying key knowledge gaps. COPC has been an effective strategy elsewhere, most notably Brazil. This scoping review investigated COPC in the sub-Saharan African context and looked for evidence of different models, effectiveness and feasibility. Methods Databases were systematically searched using a comprehensive search strategy to identify studies from the last 10 years. A methodological guideline for conducting scoping reviews was followed. A standardised template was used to extract data and compare study characteristics and findings. Studies were grouped into five categories: historical analysis, models, implementation, educational studies and effectiveness. Results A total of 1997 publications were identified and 39 included in the review. Most publications were from the last 5 years (n = 32), research (n = 27), from South Africa (n = 27), focused on implementation (n = 25) and involving case studies (n = 9), programme evaluation (n = 6) or qualitative methods (n = 10). Nine principles of COPC were identified from different models. Factors related to the implementation of COPC were identified in terms of governance, finances, community health workers, primary care facilities, community participation, health information and training. There was very little evidence of effectiveness of COPC. Conclusions There is a need for further research to describe models of COPC in Africa, investigate the appropriate skills mix to integrate public health and primary care in these models, evaluate the effectiveness of COPC and whether it is included in training of healthcare workers and government policy.

(Anesth Analg. 2018;126:2056–2064) In low- and middle-income countries like Zimbabwe, cesarean delivery (CD) is the most common surgical procedure, and as such, can indicate overall surgical activity in a health care system. Recent studies have shown the highest risk of anesthesia-related maternal death occurring in sub-Saharan Africa. Using a questionnaire, the authors of the present study assessed the type of anesthesia used for CD, level of training of anesthesia providers, and availability of resources in provincial, district, and mission hospitals in Zimbabwe.

BACKGROUND:Depression and anxiety symptoms are reported to be common among university students in many regions of the world and impact on quality of life and academic attainment. The extent of the problem of depression and anxiety among students in low- and middle-income countries (LMICs) is largely unknown. This paper details methods for a systematic review that will be conducted to explore the prevalence, antecedents, consequences, and treatments for depression and anxiety among undergraduate university students in LMICs.METHODS:Studies reporting primary data on common mental disorders among students in universities and colleges within LMICs will be included. Quality assessment of retrieved articles will be conducted using four Joanna Briggs critical appraisal checklists for prevalence, randomized control/pseudo-randomized trials, descriptive case series, and comparable cohort/case control. Meta-analysis of the prevalence of depression and anxiety will be conducted using a random effects model which will generate pooled prevalence with their respective 95% confidence intervals.DISCUSSION:The results from this systematic review will help in informing and guiding healthcare practitioners, planners, and policymakers on the burden of common mental disorders in university students in LMICs and of appropriate and feasible interventions aimed at reducing the burden of psychological morbidity among them. The results will also point to gaps in research and help set priorities for future enquiries.SYSTEMATIC REVIEW REGISTRATION:PROSPERO CRD42017064148.

Primary healthcare (PHC) can be seen as a set of values and principles that guide the health system in its policy, leadership and governance, commitment to universal health coverage and primary care.1 Governance, economics and the primary care workforce are the key structural determinants of effective primary care systems.2 The African continent has 25% of the global disease burden, but only 3% of the world’s health workers and less than 1% of the world’s health expenditure.3 The burden of disease in Africa has historically been dominated by acute and infectious diseases such as malaria, diarrhoeal diseases, lower respiratory tract infections, tuberculosis and measles. Over the last 25 years, however, chronic communicable and non-communicable diseases, such as HIV/AIDS, ischaemic heart disease, stroke and diabetes have become major contributors to the burden of disease.4 Additional contributors include newer threats such as Ebola and global warming, conflicts and displacement of persons, issues of gender and poverty with high rates of interpersonal violence, disadvantage for women in education and earnings and continued high risks during pregnancy and childbirth. Government in Africa is often characterised by flawed democracies and authoritarian regimes, which may not prioritise healthcare.5 Few countries meet the target of 15% of general government expenditure on healthcare that was agreed in the Abuja Declaration of 2001.6 In low-income countries, there are fewer resources to go around, and those resources available are often concentrated in prestigious central referral hospitals. Most countries meet the WHO criteria for having a critical shortage of health workers, defined as fewer than 2.28 doctors, nurses and midwives per 1000 population.7 Health systems in many countries, such as Malawi, rely on mission hospitals, non-government organisations and external donors to fund and provide services.8 These agencies often drive vertical disease-orientated programmes, skew central planning …