Responses to the reviewer 1
1. The term "FLMDs" sits uncomfortably - not sure if this may be due to translation?
The accepted term is primary care doctors or primary care physicians (general/generalist
doctors providing first-contact care at the primary level of care in the health system).
The term family doctor is used by WONCA. This reviewer would strongly recommend that
the authors consider changing to one of these terms, as "FLMDs" makes it difficult
to relate to other research on the supply of primary care doctors or the primary care
workforce (human resources for health). If the authors strongly feel that they would
like to stick to the new term, they will have to make a stronger case, as the current
text is unconvincing.
Our response
We thank the reviewer for his suggestions. We did not use the terms “family doctors”
or “family physicians” because they usually imply that the doctor would have a specific
training in family medicine. The WONCA Europe indeed defines family doctors/physicians
as “specialist physicians trained in the principles of family medicine/general practice
(1)”. In Africa, the statement of consensus on family medicine stipulates that “a
family physician has postgraduate training in Family Medicine” (2). Not all of the
doctors described in this manuscript have received training in the principles of family
medicine/general practice.
The terms "primary care doctors" and "primary care physicians" refer to physicians
who provide primary care, i.e. at the first level of contact between people and a
professional health worker. The Institute of Medicine (IOM) defines primary care as
"the provision of integrated, accessible health care services by clinicians who are
accountable for addressing a large majority of personal health care needs, developing
a sustained partnership with patients, and practicing in the context of family and
community" (3). Our review is studying the practice of “medical doctors who work at
the first line of healthcare delivery in SSA and provide all-around care to the population,
without distinction based on the age, the sex or the clinical condition”. This definition
is close to the definition of “primary care doctors” or “primary care physicians”.
However, our review excludes doctors who work exclusively at the hospital level. And
in some instances, primary care physicians do work only at the district hospital level
(i.e. the second-line or referral level of healthcare) as some aspects of primary
care can, rightly or wrongly, also be provided at this level.
In conclusion, we propose using the term "primary care physicians" instead of "first-line
medical doctors", as suggested. However, we made clear in the paper that we are limiting
our analysis to "primary care doctors" working at the first-line of local healthcare
delivery systems.
Therefore, in the introduction section, we included a paragraph providing a clear
definition of our study population (see line 105 to line 113 in the revised manuscript).
2. On page 15, line 211, it is stated that the PRIMAFAMED network was created in 2017.
This is factually incorrect. The origins of this network may be traced back to 1997.
The name Primafamed was used for the first time in 2008. See editorial by founder
Prof Jan de Maeseneer: https://phcfm.org/index.php/phc8fm/article/view/1603/2247.
Our response
Thank you for the correction. We corrected this. The current statement in the manuscript
is: "The Primary Care and Family Medicine Education Network (PRIMAFAMED), created
in 2008 and the collaborative projects that preceded it since 1997, helped in this
harmonisation of FPs' training in SSA" (see line 280 to 282 in the revised manuscript).
3. On page 17, lines 250 onward, you might also wish to look at the national position
paper drafted for the South African health department: https://scholar.sun.ac.za/handle/10019.1/99785; and a recent paper in the South African Health Review: https://www.hst.org.za/publications/South%20African%20Health%20Reviews/Chap%204%20Family%20Physicians.pdf. You will find that even though it appears that FPs are integrated in health and
human resources policies, there is still a fair degree of ambiguity around the roles
and scope of practice of FPs.
Our response
Thank you for this comment and the valuable documents provided. We agree that there
is still ambiguity regarding the roles of FPs. Therefore, we have improved the analysis
of the FPs' governance, and we revised the wording of this chapter to take this ambiguity
into account. For example, we stated that in South Africa "Family physicians are acknowledged
in several policy documents, although it appears that these documents still need to
fully apprehend and integrate the FPs' roles" (see line 325 to 327). We also raised
the fact that there is not always a clear understanding of the family physicians'
roles (see line 333 in the revised manuscript), and that the family physicians may
sometimes be inadequately positioned within the system (see line 335 to 336 in the
revised manuscript).
4. On page 20, lines 312 - 314: whilst the Primafamed network has played a big role,
it is incorrect to attribute all the expressions of family medicine in Africa to this
network. There are many additional North-South and South-South influences over several
decades, especially Nigeria, Uganda, Kenya and others.
Our response
Thank you for the comment. We corrected this part to highlight more these influences.
See the following passage, from line 393 to 396 in the revised manuscript: "These
roles were developed in the RSA, but other English-speaking African countries have
adopted similar roles thanks to several North-South and South-South collaborations
such as the PRIMAFAMED network or partnerships between African universities for implementing
family medicine in several countries". We had also mentioned the North-South influences
(especially the support from the Canadian and Belgian universities ) while describing
the family physicians' professional identity (see line 198 to 201 in the original
manuscript and line 267 to 270 in the revised manuscript).
5. It has to be stated that the term general practitioner also carries a fair degree
of ambiguity and confusion. In the international context, the terms general practitioners
and family physicians/doctors are often used interchangeably for primary care doctors
with 2 - 4 years of postgraduate training (see the Besrour series and the WONCA publications).
Furthermore, in South Africa general practitioners refer to primary care doctors without
postgraduate training who work in first level of care in the private healthcare sector,
whereas medical officers refer to primary care doctors without postgraduate training
who work across the levels of care in the public healthcare sector.
Our response:
Indeed the term "general practitioner" has different meanings depending on the context.
However, in the documents we reviewed, this term referred to primary care physicians
who had neither a postgraduate training in a medical sub-speciality nor a postgraduate
training in the principles of family medicine or primary care (fig 2 in the revised
manuscript). Besides, in a number of countries (Benin, Senegal, Ethiopia for instance),
"general practitioner" can refer to primary care physicians working in both the private
and public sectors.
6. On page 27 in line 415, this is one example where the authors state that FPs "work
mainly in hospitals", which is factually incorrect, as FPs are trained to work especially
in the district health services (first level of care which spans from community based
care to first level hospital/district hospital care, and includes primary health care
facilities such as community health centres and clinics).
Our response
Thank you for raising this point. Some documents we reviewed indicate that by force
of circumstances (such as the limited number of family physicians or the lack of clear
understanding of their roles) and because of their high-quality training, a number
of family physicians find themselves positioned at the district hospital level (whose
central function is normally not to provide first contact care) or even at higher
levels of care (4–6). However, we recognize that family physicians also work in community
health centres and clinics (7, 8). That is why we have corrected the statement "FPs
work mainly in hospitals" and similar statements by specifying that FPs work at all
levels of the health care delivery system (see for example line 397 to 402 and line
514 in the revised manuscript).
7. The conclusions drawn do not ring true unfortunately. Although the authors state
that their scoping review followed rigorous methodology, the analysis and interpretation
does not match the findings of similar scoping reviews or observational studies included
in this review. It is recommended that the authors review their findings and interpretations,
and perhaps ask for another expert opinions from the African primary care context
to corroborate their interpretations/theories.
Our response
In this scoping review, we carefully analysed a wide range of peer-reviewed publications
and grey literature. We mainly based our methodological approach on the methodology
proposed by Arksey and O'Malley, which includes six steps: identification of the review
question, identification of relevant studies, study selection, charting the data,
collating, summarising and reporting the results and consultation of stakeholders.
For the consultation of stakeholders, we presented the results to students in the
Master in Public Health at the Institute of Tropical Medicine of Antwerp in September
2019. Many of these students were Africans and primary health care professionals,
including primary care physicians. Also, we had informal discussions with other PhD
students and African primary health care actors (from Uganda and Guinea in particular)
to get further insights into primary care physicians' practices in their respective
countries.
Moreover, although the data analysis was qualitative (making it difficult to rule
out the authors' positionality completely), we endeavoured to ensure the validity
and the reliability of the findings through an iterative analysis process. We adopted
a transparent and systematic approach to synthesise the themes that emerged from the
data analysis (see line 161 to 172 and line 232 to 260 in the revised manuscript),
and we strived to accurately present in the results part the findings of the papers
we reviewed. Also, although the review does not include opinion papers and conference
proceedings, we used some of them (9–12) to discuss the findings, as a way of taking
into account the point of view of other African primary care experts (see for example
line 586 to 588 in the revised manuscript).
We nevertheless recognize the importance of validating the findings of such an important
and sub-Saharan Africa-wide review by a wide range of experts. Therefore we are grateful
for your inputs and critical analysis. We also invited three additional colleagues
from three different African countries to critically analyze the results and determine
whether they resonate with their countries' reality. One of these colleagues (EW,
from Kenya, who has conducted doctoral research on patient-centred care at primary
care level in Uganda) is now included among the co-authors because of her substantial
contribution to the manuscript's improvement.
Finally, we recognize that we cannot draw definitive conclusions from this study because
of the scoping review methodology's intrinsic nature. For this reason, we nuanced
some of our conclusions because they are indeed hypotheses that need to be further
tested by empirical data. For instance, instead of affirming that the primary care
physicians are poorly integrated into local health systems, we have highlighted the
existing ambiguity and pointed to the specific issues reported in the papers reviewed
(see line 547 to 552 in the revised manuscript). Similarly, we emphasized more the
need for further empirical research before concluding on the primary care physicians'
contribution to sound primary care (see lines 516 to 517, 591 to 592 and 612 to 616
in the revised manuscript, for example).
7’. The authors are from two African countries only (Benin and DRC, both francophone),
whereas the remaining authors are from Belgium. The concern is that this background
of the authors may limit their perspective when engaging with the findings of the
scoping review. Furthermore, it appears as if the authors are based in public health
and do not have a primary care/family practice background? Please provide more information
on the professional backgrounds of the authors.
Our response
Most of the authors (KB, SB, EW, JPD, JDLP, LA and BC) have worked (or even currently
work) at primary care level. The authors from Belgium have a huge experience in low-and-middle-income
countries, especially in sub-Saharan Africa, and have an accumulated experience of
many decades on primary health care in Europe, Africa and Asia.
The first author (KB) is a public health doctor indeed, but she is also a General
Practitioner and worked for ten years (2008 to 2018) as a primary care physician at
the first-line of healthcare delivery in Benin. Even if she had to temporarily suspend
her clinical activities because of her PhD program, she is still in close touch with
the primary care physicians in the field. Her PhD research focuses precisely on the
analysis and improvement of the practices of these primary care physicians.
JDLP is professor of family medicine at the University KU Leuven in Belgium. He is
a family physician for decades, and he is the leader of a writing group on mental
health in Primary Care within the European Forum for Primary Care (EFPC). In his unit,
several PhD programs are conducted in low-and-middle-income countries.
JK and SB are Congolese physicians with a very good knowledge of the local health
systems' organisation in their country. SB is a district medical officer, and he has
good insights into the practices of primary care physicians in his health district.
Moreover, he recently conducted a study on primary care physicians in Kisangani, DR
Congo. This study was recently published in French in the African Journal of Primary
Health Care and Family Medicine.
JPD is a public health doctor and health policy and systems researcher from Benin.
He has a good command of several research methodologies, including the scoping review
methodology. He has also worked as a primary care physician at the beginning of his
medical career.
EW is a registered nurse from Kenya and a health systems researcher and quality of
care change agent. She is currently writing up and finalizing her PhD thesis on understanding
the challenges and opportunities in implementing patient-centred primary health care
in Uganda. She has a good experience of the health care organization within health
districts in Kenya and Uganda.
LA is a clinical doctor and a post-doctoral researcher at the Institute of Tropical
Medicine in Antwerp, Belgium. He is from Belgium and is a trained Family Physician
who worked for several years in a primary care practice. Later he worked for more
than ten years in Africa, mainly in Zimbabwe but also in Kenya, DR Congo and Morocco.
In Zimbabwe, he held several positions at primary health care level, including medical
officer and district medical officer.
MZ is a professor of internal medicine at the University of Abomey Calavi, in Benin.
He has been teaching to undergraduate medical students for more than twenty years.
He is also involved in the training of other primary care clinicians, and he has been
the deputy director of Benin's national nursing school for three years. Besides his
teaching and clinical activities, he contributes to several initiatives for primary
care improvement in Benin.
BC is a professor of public health at the Institute of Tropical Medicine Antwerp.
He has over 30 years of experience in the organisation and management of local health
systems and primary health care (including family medicine), in Belgium and a wide
range of African and Asian countries. He is currently coordinating health systems
strengthening projects in the Democratic Republic of Congo, Guinea (Conakry), India,
Mauritania and Uganda.
Three examples of incorrect/incomplete interpretation are presented here (there may
be more issues to be identified by other reviewers):
7.1 For instance, stating that "GPs are left on their own", "FMLDs are poorly integrated,
if at all, into local health systems and national health policies" (page 30, lines
492 - 493) appear to be a one-sided view and a simplistic assessment of a complicated
issue spread across a diverse context. Such sweeping statements do not do justice
to the intricacies faced by different country settings in Sub-Saharan Africa. It will
be good to review the status of postgraduate FM training in Africa, as reassessed
in 2019 during a Primafamed network meeting, which clearly highlights the various
stages of change/engagement with this discipline across the network: https://phcfm.org/index.php/phcfm/article/view/2588/4132.
Our response
We tried to bring out this complexity by presenting and discussing the variability
in primary care physicians' practices in Sub-Saharan Africa. The first part of our
discussion concerns this variability and complexity (line 503 to 545 in the revised
manuscript). Moreover, throughout the manuscript, we highlighted as much as possible
the differences between countries, and we exposed the differences between the different
types of primary care physicians in Sub-Saharan Africa. For example, we exposed that
even though several papers reported that GPs in the private sector are business-oriented,
other papers indicate that these GPs can opt for a publicly oriented service delivery
(line 317 to 319 in the revised manuscript).
However, as explained above, we improved the manuscript by avoiding too general conclusions.
7.2 Also stating that "The GPs tend to be concentrated in urban and wealthier areas,
whereas private GPs do not always contribute to public health programs." (lines 456
- 457 on page 29) is untrue, as GPs also offer access in low/middle income settings
(for example, South African "townships") where access to public sector primary care
services is poor.
Our response
Thank you for raising this point. We revised the wording of this part. We now stated
that: "there were also concerns regarding the accessibility, the comprehensiveness
and the continuity of the services offered by the GPs" (see line 588 to 590 in the
revised manuscript). Indeed, several studies have reported that private GP services
are mainly accessible to people who can afford it (see line 486 to 487 in the revised
manuscript). This may be because many private GPs need to be paid out-of-pocket or
via private health insurance, which some people cannot afford. Other studies also
reported a focus on curative care among some GPs (see line 490 to 491).
We nevertheless recognize that these issues are not necessarily found among all the
GPs. And we specified it in the revised manuscript (see line 491 to 493 in the revised
manuscript). Besides, we have highlighted that the private GPs can offer an alternative
when the public primary care services are poorly available (see line 392 to 395 in
the original manuscript and lines 484 to 486 in the revised manuscript).
7.3 Statements on impact made by family physicians on page 22 (lines 370 - 372) are
also incomplete. Whilst correlation analysis between FP supply and routine health
indicators showed no impact due to low supply (reference 40), it should be noted that
a cross-sectional study (reference 90) showed impact especially in district hospital
regarding child healthcare indicators, as well as perceived impact from the perspectives
of co-workers and district managers (references 86 and 73 respectively).
Our response
We presented the perceived impact of family physicians and their positive effect on
the access to care, the clinical processes and some health outcomes, especially those
related to mother and child health (line 411 to 416 in the original manuscript).
However, we recognize that the statement "The rare studies that have evaluated the
impact of FPs on the performance of local health systems were performed in the RSA,
and they could not demonstrate any impact" (line 420-422 of the original manuscript)
was not precise enough. We were specifically referring to the family physicians' impact
on health outcomes such as child mortality, maternal mortality, mother to child HIV
transmission rate, etc. We thus revised this part as follows: "We found only a few
observational studies that have evaluated the impact of FPs on health outcomes (such
as child mortality, maternal mortality or mother to child HIV transmission rate).
These studies were limited to the Republic of South Africa. They could not demonstrate
a significant impact of the family physicians on health outcomes, despite the positive
impacts reported on clinical processes and accessibility. This was attributed to the
limited number of FPs" (see line 457 to 461 in the revised manuscript).
We have also reorganised the outputs/outcomes section to separately present the primary
care physicians' impact on the quality of primary care and their impact on health
outcomes (from line 444 to 494 in the revised manuscript). For instance, for the specific
case of the family physicians, we first presented the impact of the family physicians
on the access to care, the quality of the clinical processes, and other aspects of
primary care (line 445 to 457 in the revised manuscript). We then discussed their
impact on health outcomes (see line 457 to 461 in the revised manuscript).
References
1. WONCA Europe. The European definition of general practice / family medicine- 2011
Edition [Internet]. Europe; 2011. Available from: http://www.woncaeurope.org/.
2. Mash R, Reid S. Statement of consensus on Family Medicine in Africa. Afr J Prim
Heal Care Fam Med. 2010;2(1):4–7. DOI: 10.4102/phcfm.v2i1.151.
3. Committee on the future of primary care. Primary Care: America’s Health in a New
Era. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, editors. National Academy Press.
Washington D.C.; 1996. https://www.ncbi.nlm.nih.gov/books/NBK232643/.
4. Flinkenflögel M, Sethlare V, Cubaka VK, Makasa M, Guyse A, De Maeseneer J. A scoping
review on family medicine in sub-Saharan Africa: Practice, positioning and impact
in African health care systems. Hum Resour Health. 2020;18(1):1-18. DOI: 10.1186/s12960-020-0455-4.
5. Besigye IK, Onyango J, Ndoboli F, Hunt V, Haq C, Namatovu J. Roles and challenges
of family physicians in Uganda: a qualitative study. Afr J Prim Health Care Fam Med.
2019;11(1):1-9. DOI: 10.4102/PHCFM.V11I1.2009.
6. Mash R, Von Pressentin KB. Strengthening the district health system through family
physicians. South African Heal Rev 2018; 2018: 33–39. DOI: 10.10520/EJC-1449142b2d.
7. Von Pressentin KB, Mash RJ, Esterhuizen TM. Examining the influence of family
physician supply on district health system performance in South Africa: an ecological
analysis of key health indicators. Afr J Prim Health Care Fam Med. 2017 Apr;9(1):1-10.
DOI: 10.4102/phcfm.v9i1.1298.
8. Von Pressentin KB, Mash RJ, Baldwin-Ragaven L, Botha RPG, Govender I, Steinberg
WJ , et al. The Influence of family physicians within the South African district health
system: a cross-sectional study. Ann Fam Med. 2018 Jan;16(1):28-36. DOI: 10.1370/afm.2133.
9. Reid S, Mash B, Thigiti J, Nkombua L, Bossyns P, Downing R, et al. Names and roles
for the generalist doctor in Africa. Afr J Prim Health Care Fam Med. 2010;2(1):1-5.
DOI: 10.4102/phcfm.v2i1.242.
10. De Maeseneer J. Scaling up Family Medicine and Primary Health Care in Africa :
Statement of the Primafamed network , Victoria. 2013;5(1):1-3. DOI: 10.4102/phcfm.v5i1.507.
11. De Maeseneer J, Flinkenflogel M. Primary health care in Africa: do family physicians
fit in? Br J Gen Pract. 2010 Apr;60(573):286-92. DOI: https://doi.org/10.3399/bjgp10X483977.
12. Moosa S, Peersman W, Derese A, Kidd M, Pettigrew LM, Howe A, et al. Emerging
role of family medicine in South Africa. BMJ Glob Health. 2018;3:2-4. DOI: 10.1136/bmjgh-2018-000736.
Responses to reviewer 2
1 PONE-D-20-25494 Review General: This manuscript is the write up of a scoping review
that was conducted to examine “…the current literature on First Line Medical Doctors
(FLMD) in Sub-Saharan Africa (SSA)…” in order to “identify the knowledge gaps” (p.2
Protocol) about “what are the main characteristics and key issues of FLMD practices
in SSA” (lines 92-93). Reviewing the literature over the past 19 years (2000-2019)
in both English and French using a number of pre-identified search terms in five databases
and purposively sampling some grey literature, the authors include 73 peer-reviewed
(or original) research publications in their final analysis. The results indicate
a range of publications, largely from South Africa (47%), and written in English (67%),
although there are a number of papers (29%) from French-speaking Africa. There is
great heterogeneity in the nomenclature of these “first line” doctors across SSA;
and, the authors propose a bilingual classification based on how the literature refers
to them. The authors subsequently construct three categories of FLMDs after examining
their scope of practice and responsibilities whether in Anglophone Africa or in la
Francophonie. Going systematically across four components of the health system (professional
identity; governance; roles and activities; and, output and outcomes) for each type
of FLMD (Family Physician; medicin generalist communautaire; or General Practitioner)
the study reveals interesting observations about how, where, why and under what conditions
these doctors work. These findings have important repercussions for national and regional
health systems planners in Africa as well as newly qualified doctors deciding on career
pathways. The paper also exposes significant gaps in research on medical doctors who
function at primary care level, especially those in private practices across SSA and
in rural areas as solo practitioners (as opposed to those placed there as part of
government and/or NGO programmes). There is also little understanding of the return
on investment in this cadre of health care worker vs the risks. In summary, this article
provides a refreshing look at task shifting in reverse and posits that when medical
doctors move from referral centres into primary care spaces across Sub-Saharan Africa,
there may be unforeseen consequences that could be managed with better role definition,
governance and policies. It is critically important to understand the phenomenon of
a shift of doctors away from referral hospitals into communities and clinical spaces
while attending to undifferentiated patients at the primary care level, especially
as these doctors engage patients and communities at points of first contact that were
historically reserved for nurses. There are also potential policy decisions in resource
constrained environments, since training and upskilling medical doctors to occupy
roles in primary health care represents a costly investment. This is arguably a novel
and relevant topic for a scoping review, and potentially can make substantive contributions
towards addressing some of the human resources for health challenges, as well as the
political and ethical ones. Finally, this paper represents an ambitious project; and,
the amount of work and reflection are obvious. The original research protocol is included
as supplemental material, and indicates that this is part of a PhD from a candidate
in Benin being supervised in Belgium. It is important for ISI and mainstream medical
journals to publish articles about Africa, especially those conceived and written
by Africans.
Our response
Thank you for reviewing this article and for the positive appreciation of our work.
Your further comments significantly contributed to improving our work. We are grateful
to you for highlighting that the progressive shift of medical practice from mainly
referral centres to primary care spaces in Sub-Sahara Africa may have unforeseen consequences
if not properly managed. We hope that our findings will shed light on this issue and
trigger further research and actions to guide primary care physicians' practices towards
better primary care in SSA.
Major: There are several significant conceptual framings to the manuscript and methodological
decisions that, to my mind, require clearer explanation and more rigorous justification
in the text. I have outlined these in the first three points below, followed by other
major issues in no particular rank order of importance:
1. Including a more robust definition of the "first-line medical doctor" (FLMD) in
the introduction is critical. Although FLMDs are the cornerstone of this study, this
is not a common term in the medical literature, nor is it one with which most readers
(even Englishspeaking medical generalists) would be familiar. A clear definition of
FLMDs will enable the article to reach the broader medical community and articulate
with conversations in other journals about the deployment of primary care doctors
in SSA and their scope of practice. To illustrate the limitation of the use of FLMD:
when I tried to search within the PLOS ONE option for similar publications on MEDLINE,
this is the message I received: "Your search was processed without automatic term
mapping because it retrieved zero results." Similarly, when I used "first line medical
doctor" in PUBMED on 2020/10/25, this is the response I got: "Quoted phrase not found."
In Google scholar (albeit not ideal), there were eight results (five unique, three
duplicates, one from Quebec, the rest European). For a predominantly English audience,
this term needs more unpacking, and will probably necessitate revision of the title
of the manuscript to in order to resonate with a wider (and more appropriate) audience.
Our response
We acknowledge the limitations of using the term "first-line medical doctor". We
decided to replace it with "primary care physicians" (PCPs) to better relate with
other research on the primary care workforce. We also included in the introduction
section a paragraph providing a clear definition of the study population (see line
105 to 113 in the revised manuscript). We formulated this paragraph as follows:
"In our review question, PCPs are defined as medical doctors who work at the first
line of healthcare delivery in SSA and provide all-around care to the population,
without distinction based on the age, the sex or the clinical condition. We excluded
doctors who work exclusively at the hospital level because the novelty of the phenomenon
we are studying lies on the shift of medical practice from hospitals to the first-line.
We also limited the study to physicians who provide all-round care to the population
because the key function of the first-line is to provide primary care, which is defined
by the Institute of Medicine as "the provision of integrated, accessible health care
services by clinicians who are accountable for addressing a large majority of personal
health care needs, developing a sustained partnership with patients, and practising
in the context of family and community".
We also defined the first-line, in relation to health districts and primary health
care (see line 60 to 66):
“In Sub-Saharan Africa (SSA), many countries operationalise PHC within health districts,
which encompass a network of formal health facilities, community-based services, and
other supporting services and health programs. The formal healthcare delivery platform
includes small to medium size public and private facilities (the first line) which
should normally be the first entry point in this platform and should deliver primary
care, dealing with the majority of the population's health needs. These first-line
facilities (called dispensaries, health centres, community health centres or clinics,
depending on the context) are supported by a district hospital (the second line) which
is the first referral level.”
Finally, we revised the title based on all of the above. The current title we propose
is: "The expanding movement of primary care physicians operating at the first line
of healthcare delivery systems in sub-Saharan Africa: A scoping review".
2. There is an uneasy linkage between FLMDs in the manuscript (whose role is largely
clinical) and the pillars of health systems research. I could not find sufficient
justification for the use of the health systems dynamics framework (Reference 27)
as the sole basis for categorising the articles and creating a data extraction form
(lines 117 – 120). Since the data extraction form does not appear to be included in
either the body of the paper or in the supplemental files, it is unclear exactly what
data were extracted from which articles onto an Excel spreadsheet. This omission also
speaks to the limited availability of data, which is something PLOS ONE requires.
Furthermore, it seems that this framework gets jettisoned later in the Discussion
and Conclusion, failing to take full advantage of the model in its ability “to deal
with complexity/its dynamic character/and the values embedded in it.” There is no
convincing explanation as to why the framework was employed to begin with, since “health
systems” is not included in the key words, nor were these different components (“governance”;
“resources”; “service delivery”; “relationships with the community context”; “values
on which the health system is based”; and, “outcomes”) used in the search strategy
at the outset. Rather than allowing the themes of the scoping review to emerge organically
and synergistically through iterative discussions among the authors (as it seems might
have been the case anyway in Table 5), the method of using the ‘health systems dynamics’
framework could have restricted the reviewers’ vision of appreciating the actual subject
matter being covered by these 73 articles. Without access to the Excel data extraction
form, and only the S3 Table (List of papers included), it is difficult to understand
the data items and the data charting process. As a reviewer, it would have been important
to confirm the fields on the data extraction form, and look for alignment on several
of the articles through a trial run. At the moment, none of this is replicable. Being
familiar with some of the literature, it seems that several important (and statistically
significant) outcomes were not adequately captured.
Our response
In the revised manuscript, we explained why we used the health systems dynamics framework
to construct the data extraction form (see line 150 to 156).
Although the role of PCPs who work at the first-line is mainly clinical, their practice
should contribute to improving the performance of the whole health system. Moreover,
the other components of the health system (for instance the governance arrangements,
the general context or the resources available) influence the roles assigned to these
PCPs, their activities and even the results achieved. For example, we could see that
the family physicians' efforts to apply primary care values are often undermined by
the hierarchical culture in their context or by a high workload (which is sometimes
due to the fact that they endorse the role of other specialists who are lacking in
district hospitals). So, using the health systems dynamics framework as a starting
point for constructing the data extraction form helped us systematically look at the
information on each of the health system elements in relation to the practice of PCPs.
Furthermore, the framework guided our analysis of the data extracted from the documents
reviewed. Some of the themes and dimensions used in this review for analysing the
PCPs' practices (table 4 in the revised manuscript) are elements of the health system
dynamics framework or derived from them (for example governance, values and outcomes).
The additional themes and dimensions emerged from the data in two ways. First, apart
from the predefined fields in the data extraction form, the reviewers extracted additional
data when deemed necessary. Second, during the data analysis and synthesis process,
the themes were iteratively discussed and refined, allowing for identifying sub-themes
(for instance, the historical pathway) and grouping some themes into the dimensions
presented in table 4. We have better explained this analysis process in the methodology
section (see line 162 to 172 in the revised manuscript).
Finally, although we did not directly use the health system dynamics framework in
the discussion and conclusion parts, we strived to bring out the relationships between
the various elements, as recommended for an analysis taking a health system perspective.
This helped us link the governance of PCPs to their activities and to their contribution
to primary care, in the discussion section. For example, we highlighted the potentials
links between the policy guidance, the activities of the PCPs and the outcomes of
their practices (see line 560 to 566 in the revised manuscript). We did a similar
analysis in the original manuscript from line 430 to 435.
3 . Aside from not using any of the key components of the ‘health systems dynamics’
framework above in the search strategy, such as “service delivery”, there seem to
be other aspects of the search strategy that are not clear or do not align with the
stated objectives of the scoping review extracted below from the Protocol (S1 Text):
- This scoping review aims at […] providing an overview of the current literature
on First Line Medical Doctors (FLMD) in Sub-Saharan Africa and identifying the knowledge
gaps. (p 2 Protocol) - General objective: the general objective is to map the existing
knowledge on First Line Medical Doctors (FLMD) in Sub-Saharan Africa and to identify
the key issues in this area. - Specific objectives and research questions: a. Determine
the various types of medical Doctors operating at the level of first-line in SSA b.
Map the key dimensions that have been studied on FLMD in Sub-Saharan Africa (training,
resources, services delivery, leadership and government [sic] arrangements, etc.)
c. Determine the key issues related to FLMDs’ practice in Sub-Saharan Africa My specific
questions in this regard are:
3.1 While the justification for starting the search from the year 2000 is based on
the prevalence of articles dating from that year (line 102), there may be foundational
publications that could have been missed. Having been part of early debates that dealt
with questions of professional identity and the need for a values-driven medical practice
at primary care level in SSA ("one family"/"one doctor"), it seems prudent to go back
to the 1990's, or provide a stronger justification for limiting the search to publications
dating from 2000 other than convenience. Even if the year 2000 is retained, this decision
could be dealt with in the discussion, with reference to earlier seminal articles
not included in the scoping review, in order to apply a historical/ contextual dimension
and evolutionary analysis to what has been published over this nearly 20 year period
and how it has developed over time.
Our response
Apart from the prevalence of articles dating from 2000, another reason for starting
the search in 2000 is the fact that some of the papers written after 2000 provided
information on the development of the primary care physicians in sub-Saharan Africa
going back to earlier years. For instance, the papers by Dugas et al. “La construction
de la médecine de famille dans les pays en développement” (1) and by Desplats et al.
"Pour une médecine générale communautaire en première ligne" (2) provide information
and insight on the development of the "médecins généralistes communautaires". Concerning
the family physicians, the papers by Hellenberg et al. "Family medicine in South Africa:
where are we now and where do we want to be?"(3), Moosa et al ."The views of key leaders
in South Africa on implementation of family medicine: critical role in the district
health system" (4), and other papers provided a summary of the development of family
medicine in the Republic of South Africa. We also found papers describing the development
of family medicine in other countries such as the paper by Makwero et al “A. Family
medicine training and practice in Malawi: history, progress, and the anticipated role
of the family physician in the Malawian health system” (5).
We nevertheless acknowledge the relevance of applying a historical and contextual
dimension to the analysis to fully understand the practices of PCPs in Sub-Saharan
Africa, especially how the specific African context and the early discussions have
shaped these practices and the values that should drive them. Therefore, we discussed
the role that the historical pathway of each of the three categories of PCPs may have
played in the current expression of their practices (see line 520 to 533 in the revised
manuscript). Furthermore, we had already discussed how the expectations that African
stakeholders have of physicians might have influenced their activities and performance
regarding primary care (see line 593 to 600 in the revised manuscript).
3.2 Why was there a decision to leave out government policy documents on the deployment
of FLMDs? It seems that inclusion of this type of grey literature would be important
in order to answer the research question/objectives of the study. Through government
documents or discussion papers, each country in SSA might have been represented in
ways that publishing in peer-reviewed indexed journals with high APCs would never
be possible. The authors might perhaps consider explaining this exclusion and adding
it to the section on limitations.
Our response
We only had access to government policy documents for some countries, and it was not
easy to get them for the other countries without a primary data collection. So, we
decided to leave out these documents in order to avoid a potential selection bias.
However, we definitely agree that the exclusion of government policy documents is
a limitation of this study. We acknowledged it in the strengths and limitations section,
from line 626 to 627 in the revised manuscript.
3.3 Also on the matter of grey literature, it is unclear as to why other NGOs (besides
Sante Sud) or University Medical Faculties or professional groupings of primary care
practitioners (besides PRIMAFAMED) or religious groups working in SSA were not purposively
sought out. As notional examples, I am thinking of government-to government agreements
between Cuba and countries in SSA to supply first line doctors; MSF and other humanitarian
relief agencies; CHAI support to the training of medical doctors in Rwanda; etc.
Our response
We acknowledge that we did not comprehensively search for the grey literature, and
we explicitly include this in the "limitations" section of the paper (see line 628
to 630 in the revised manuscript). However, throughout the review process, we attempted
to mitigate the impact of this limitation through a careful review of the papers,
including the introduction part, and a careful screening of their reference lists.
We also mentioned in the revised manuscript, the efforts from the African governments
to supply first-line doctors, including the government-to-government agreements between
Cuba and countries (see line 315 in the results section of the revised manuscript)
3.4 Since the colonisation of SSA was not restricted to the English and the French,
why was the search not trilingual to include Portuguese, or even other languages such
as German, Dutch and Flemish? There would be many SSA countries with such colonial
histories, and legacies of these relationships, whose publications might have been
missed. Again, perhaps something to include in limitations?
Our response
Thank you for the pertinent comment. We have addressed this in the limitations section
on lines 634 to 636 in the revised manuscript.
3.5 I am curious as to why an expanded search was not undertaken once certain framings
came to light through the analysis of the articles. For example, after the French
terms medecin de campagne or generaliste communautaire came up, why were the English
translations/interpretations not subsequently incorporated into the search strategy?
“Rural doctor” yields a great deal of results that do not appear to be included in
the 73 articles. Likewise, the literature on “community service doctors” in the South
African context, and perhaps others, is missing, although it appears similar to the
generaliste communautaire.
Our response
Thank you for the useful advice. We performed an additional search on MEDLINE on January
15, 2021, by including the keywords "community doctors" and "rural doctors" in the
search strategy. This yielded 53 results, of which some were duplicate of papers already
reviewed. Three additional papers met the inclusion criteria and were included in
the review. One of the papers was about the physicians trained in Cuba. We also found
some papers on the community services doctors, but, unfortunately, they did not meet
the inclusion criteria (mainly because they were reported to work in district hospitals).
We also performed an update search with the previous search strategy, starting from
June 2020. Two additional papers met the inclusion criteria.
3.6 As well, in the search strategy, it is not clear why a manual review of several
journals critical to this subject matter was not undertaken. For example, purposive
sampling of Rural and Remote Health, African Journal of Primary Care and Family Medicine
and Human Resources for Health might have yielded results that were more focussed
and/or relevant to the key questions of the scoping review.
Our response
We did a manual search of the following journals: Rural and Remote Health, African
Journal of Primary Care and Family Medicine and Human Resources for Health in January
2021. We also found several duplicates there. However, we got three additional papers.
Thank you for suggesting this manual review.
All the additional searches performed provided eight papers that were used in the
revised manuscript to support the previous finding or refine the analysis. However,
they did not introduce significant changes in the findings.
3.7 Finally, the correct reference for the PRISMA extension for Scoping Reviews (reference
26) should be Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al.
PRISMA Extension for Scoping Reviews (PRISMAScR): Checklist and Explanation. Ann Intern
Med; 169:467–473. doi: 10.7326/M18-0850. Although the correct PRISMA-ScR document
is included as “S2 Text”, it is still missing the appropriate citation in the body
of the manuscript (JBI has taken down the link in #26) as well as permission to re-print
from St Michael’s. Using Tricco et al as a guide will assist in revising the above
points as well as addressing some of what follows below
Our response
Thank you for the correction. We provided the appropriate citation for the PRISMA
extension for Scoping Reviews (Tricco and al, 2018, see reference N° 32).
Also, during the conception phase of this study, we used several methodological guides
(see reference list of the protocol, S1-text) including: "Tricco AC, Soobiah C, Antony
J, Cogo E, Macdonald H, Lillie E, et al. A scoping review identifies multiple emerging
knowledge synthesis methods, but few studies operationalize the method. J Clin Epidemiol.
2016;73:19–28" and "Alliance for Health Policy and Systems Research. Evidence Synthesis
for Health Policy and Systems : a Methods Guide. Langlois E V, Daniels K, Akl EA,
editors. Geneva: World Health Organization; 2018". We included them in the revised
manuscript references (see lines 118 to 120 in the revised manuscript and references
N° 29 and N° 30).
4. The Flow Chart, Figure 1, is missing critical information that makes it difficult
for the reader to follow why some articles were excluded at certain points and why
others were retained. In addition, aside from a brief mention of the review process
in the lines 131-132, a more robust narrative should be included in the Results section
to describe the flow chart.
Our response
We included a better narrative of the study selection process in the Results section,
from line 182 to 186 in the revised manuscript.
Specifically: 4.1 The disaggregated sources of articles should be included in the
“Identification” step, with the exact numbers sourced from each of the five databases,
rather than a combined total of n=3939. “Other sources” should also be itemised at
this point.
Our response
Thank you for the suggestion. We provided the disaggregated sources of articles, and
we itemised the "other sources" at this point (see figure 1).
4.2 The reasons for excluding 3844 records through screening the title and abstract
are not clearly articulated in either the text or in the flow diagram. Lines 112-113
indicate, that “after removing the duplicates, two of the authors independently assessed
the titles, abstracts, and full-text of the articles with predefined selection criteria
(Table 2)”, thereby appearing to merge the steps of full-text review (“Eligibility”)
with that of “Screening”. This distinction needs to be maintained, rather than simply
stating that 3844 records were excluded without providing a clear rationale or criteria
for elimination.
Our response
These issues have been addressed in the revised manuscript and the flow chart. We
provided more details on the review process in the methods section from line 139 to
145 in the revised manuscript. We also included in the flow chart the reasons for
excluding the 3844 records (see figure 1 in the revised manuscript).
4.3 The 70 articles that were excluded based on the eligibility criteria might be
valid; however, the restrictions are not completely aligned with what is outlined
in Table 2. For example, one of the exclusion criteria is “papers published before
2000” whereas in the flow 5 diagram, manuscripts were excluded because “data [were]
collected before 2000”. The reasons (inclusion/exclusion criteria) need to be consistent
and strictly adhered to throughout this process.
Our response
We actually integrated the papers which data were collected before 2000. One of the
reviewers excluded them, but after discussion, they were included. We forgot to remove
this reason from the flow chart. We apologize for this error which we have corrected
in the flow chart.
As stated above, opinion papers, commentaries and conference or workshop reports
might have been valuable to retain, given that this is a scoping (rather than a systematic)
review. The focus of the scoping review on “peer reviewed” original research requires
further justification, as indicated in Point 3 above.
Our response
We excluded opinion papers, commentaries and conference or workshop reports because
they usually express the writer's or the participants' opinion, rather than reporting
the actual practice. However, we used several of these papers in the introduction
and the discussion sections. For example, we used some commentaries to discuss the
primary care physicians' impact on the primary care performance (see line 587 to 588
and the references N° 118 and N° 127 in the revised manuscript).
Furthermore, we did not limit the scoping review to peer-reviewed papers. We included
several pieces of grey literature, especially those reporting country cases or other
case studies.
Another exclusion criterion from Table 2 “Papers relating to MDs working exclusively
in hospitals” might have inadvertently eliminated research about important cadres
of first line doctors, especially those working in rural areas in SSA, where there
may only be a district or mission hospital serving a sparsely populated area through
outreach initiatives rather than a formalised network of other PHC facilities (such
as clinics or health posts).
Our response
This is a relevant point, indeed. However, although we did our best to include the
hospital doctors who have an additional community practice, it was not easy to distinguish
all the nuances in the practices of the PCPs based on the papers. We thus included
this point in the limitations section (see line 630 to 633 in the revised manuscript).
4.4 In the "Inclusion" step, the addition of 17 articles through citation tracking
and six articles through a new search should be indicated with arrows below the box
of "Full-text articles eligible" (n=50), as well the exact date of the new search
(not only the year). These should then be merged, to add 23 articles to the 50, for
the total of 73.
Our response
We corrected this on the flow chart. Thank you for the suggestion.
4.5 Finally, although additional tables and diagrams are used in the manuscript to
describe the types of articles included, it might be useful to add a basic characterisation
of the types of sources that made the cut. This could go in below the “Papers included
in the scoping review”, and might be a classification of the number of those written
in French vs English, or about specific countries in SSA (therefore removing Figure
2), or by type of methodology (quantitative, qualitative and mixed methods)—to better
(and more graphically) indicate the heterogeneity and variety of the final selections.
Our response
In the results section, we included on page 12 a table (table 2), which provides a
characterisation of the papers included. This table presents the number of papers
written in French vs English, a classification of the papers by methodology and the
number of papers about each sub-Saharan African region.
5. While the article requires copy editing to address grammatical, spelling and punctuation
errors, there are important clarifications of terminology that might have gotten lost
in translation from French to English. Most striking amongst these are:
5.1 In the Results section, the use of “denomination” to indicate “nomenclature” or
“taxonomy” to describe the different types of FLMDs discussed in the literature. This
should be addressed in lines 138 – 140; 142, and in Table 3.
Our response
Thank you for the suggestion. We replaced the term “denomination” by "nomenclature"
or "name" "or designation" as appropriate (see for instance line 197, line 201, line
202 and table 3 in the revised manuscript).
5.2 Furthermore, some aspects of categorising these doctors into groupings based on
the descriptions of their activities seem problematic (Figure 3). For me, combining
medical officers (MOs) and GPs misses the point of general practitioners’ largely
private practices being run as small businesses with pharmacies and dispensing options
as well as niche or boutique foci, such as aesthetic medicine: they are inherently
unregulated. Ironically, however, at least in the South African context, GP practices
are stable caring for families and communities across generations. Medical officers
operating at first line, on the other hand, are never self-employed, and they often
work publically. Their contractual relationships are either with either government
or another regulatory body, such as a health insurer or syndicate of health care providers.
Like the generalistes communautaires (and community service doctors), MOs are usually
transitory remaining in a post until an opportunity for specialisation opens up. The
groupings, and conclusions subsequently drawn, do not seem plausible. Therefore, Figure
3 needs revision.
Our response
Based on the papers reviewed, we did not find sufficient arguments for making medical
officers a separate category. Of the 7 papers relating to medical officers, only 2
correctly described their practices. The others just evoke certain aspects of this
practice. So, if we had made the medical officers a separate category, it would have
been difficult to characterize them properly. Moreover, the practices of PCPs at the
first-line in the public sector may vary, depending on the context. For instance,
in Benin, they appear to be more stable than the private GPs (unlike in South Africa).
Thus, further research would be needed to define the differences between public and
private GPs more accurately. We nevertheless acknowledge that describing the GPs category
as one homogenous lot would be misleading. Therefore, we tried, whenever possible,
to bring out the possible differences between public and private GP. Examples in the
original manuscript can be found at lines 240 to 242, 245 to 246, 289 to 291 and 342
to 344. Examples in the revised manuscript can be found at lines 311 to 315, 316 to
319, 367 to 369 and 426 to 429.
Additionally, we highlighted in the discussion section these possible differences
between the public and the private GPs and the need for more research to verify and
specify these differences (see line 516 to 517 in the revised manuscript).
6 6. Discussion: The phrase "a multiform phenomenon" (line 403) needs rewording. Care
must also be taken in terms of sweeping generalisations "…in the RSA, FPs are trained
for four years and work mainly in hospitals…" (lines 415 – 416). There are regional
differences within RSA, with provinces deploying FPs to community health centres and/or
sub-districts rather than to district hospitals. Similarly, lines 425 – 429 starting
with "The FLMDs are poorly integrated into local health systems and national health
policies […]" might be over-stated from the articles available. Simply because the
authors "did not find a clear and overarching governance framework to guide FLMDs"
does not mean that in certain contexts it does not exist. It simply means that the
authors did not find it! This brings me to the point of the purposes and limitations
of this type of study and the conclusions that can in fact be drawn from a scoping
review. There is no critique in this manuscript about what types of research gets
published and indexed from the Global South, and especially from SSA. In this review,
South Africa/PRIMAFAMED/NGO Sante Sud dominate and therefore, simply put, get to tell
the story. It would behove the authors to highlight the research gaps more clearly
and raise issues around publication bias. Certain journals have annual quotas for
articles from Africa— and perhaps other parts of the Global South. APCs are prohibitive
and most journal publications are in English. Therefore, the current conclusion over-reaches
in places about what can be said from this scoping review, and should be re-framed
in the tone highlighted in line 459, "…more empirical evidence is needed before drawing
final conclusions." The study can only comment about gaps in the literature that describe
what is, or perhaps more importantly, what is not there.
Our response
Thank you for these useful comments. We agree with them, and we have carefully revised
the tone of the whole article, especially the findings and the discussion sessions.
We paid particular attention to avoiding sweeping generalization and highlighting
the research gaps. For example, we presented the situation of the family physicians
in South Africa more accurately. We specified that they could work at all levels of
the healthcare system (see lines 397 to 401 and 513 to 514 in the revised manuscript).
We also discussed the issues related to the primary care physicians' governance and
their contribution to primary care performance, without drawing overarching conclusions.
For instance, from line 547 to 552, we summarised the governance issues pointed out
by the paper reviewed without concluding that there is a "poor governance".
Furthermore, we highlighted the research gaps more clearly (see lines 537 to 545,
612 to 616 and 648 to 651 in the revised manuscript), and pointed to the potential
role of publication bias in explaining these research gaps ( line 540 to 545 in the
revised manuscript).
Finally, we removed the phrase "a multiform phenomenon" and replace it with "heterogeneity
in the PCPs’ practices in SSA” (see line 503 in the revised manuscript).
Minor:
1. In the Introduction, referencing the increasing number of doctors across Africa
per population is important but does not seem specific to the practice of primary
care. To strengthen the point, it would be helpful to include the shift towards generalism
(vs specialty training) of doctors (if this is true?) as well as overall statistics
from SSA, rather than only Benin and the DRC.
Our response
We included overall statistics on the trends in the physicians' ratio in SSA (see
lines 74 to 75 in the revised manuscript). The data on generalist physicians in SSA
is scattered and poorly available (see, for example, https://apps.who.int/gho/data/node.main.HWFGRP_0020?lang=en). However, ad-hoc observations and some previous research pointed to the increasing
presence of medical doctors at the primary care level, especially in the private sector
(1,2,6).
2. There are many tables, figures, a map, supplementary materials, etc. that are
rather overwhelming. I wonder whether some of these might be combined or omitted entirely?
I would suggest moving Table 1 (the search strategy) into an appendix, and integrating
the information from Figure 2 elsewhere.
Our response
We deleted the map and the table presenting the countries where each type of PCPs
has been reported (table 4 in the original manuscript), as the information in these
two elements is already presented in the supporting information file S5 table (list
of paper included) and in table 2 in the revised manuscript (characterisation of the
papers included). We have also moved the search strategy into the supporting information.
The numbers in Table 3 do not add up (total of 78), so it needs to be stated if there
were multiple designations of doctors studied in a single paper.
Our response
Indeed, there were multiple designations of doctors in some papers. We specified this
under table 3.
I would also recommend trying to combine information from Tables 3 and 4 with Figure
2 in some way (so the map could stay with the particular countries appropriately labelled).
The fragmentation of information makes the paper seem more complex than it is and
difficult to follow.
Our response
We deleted the table 4 of the original manuscript as the information there can be
easily retrieved from the supporting information file S5 table which presents the
country each document refers to and the name given to the PCPs in the document. We
also deleted the map as the information on this map is now in table 2 in the revised
manuscript (characterisation of the papers included).
Table 5 columns should be flipped: “Themes” on the left and “Dimensions” on the right.
I am also not sure these are the correct labels for the headings (another French to
English ‘lost in translation’?) because, as stated above, the data extraction form
is not available.
Our response
We flipped the columns as suggested. As explained now in the methods section from
line 161 to 172 and in the results section from line 230 to 231, we grouped some themes
into broader themes, based on the strong relationship we found between them. It is
these broader themes that we have called "dimensions".
We provide the data extraction form as a supporting file.
3. NB: Libya not in SSA. It might be useful to indicate or reference your source(s)
for all of the countries designated in your search strategy as being in SSA (eg: UNESCO;
World Bank; etc.)
Our response
We included Libya by mistake. The list was obtained from brainstorming and discussions
between the authors. After the reviewer's comment, we carefully reviewed the list,
based on the World Bank classification of countries. We removed Libya. Other mistakes
were not found.
4. While discussing the division of labour in the manuscript (who did what), you might
want to consider indicating this by including the authors’ initials.
Our response
We included this in the manuscript (see lines 139, 141, 143, 144 and 145).
5. Once the issues above are addressed, the abstract will require revision. Either
way, the 'PCC' should be made clear in the introduction; the Methods section would
benefit from synthesis and alignment with the text of the manuscript; the Findings
should reflect only what is included in the 73 articles under review; similarly, the
conclusion can only draw on what is published and/or identified as gaps in the literature.
I am a bit worried about some of the quantitative declarations like, "the increasing
presence of medical doctors at the first line of health care" or the assertion that
GPs "constitute the bulk of FLMDs in SSA" when it is not clear that this information
is derived from the scoping review. See comments above about possible over-stating
the concluding points. Once again, a scoping review can only draw conclusions about
what is already published, or comment on research gaps.
Our response
We revised the abstract, and we carefully avoided over-stating conclusions (see the
abstract section from line 27 to 53 in the revised manuscript).
6. The term “professional identity” within medicine has been richly explored. Lines
171 – 176 would benefit from citing some of this literature, rather than the generic
occupational reference #28. This is important to adequately set up what follows later
regarding the “Professional Identity of FLMDs” in lines 196 – 249.
Our response
Thank you for the suggestion. We used 2 more references, specific to the medical field,
to better characterize the professional identity and support the rationale for grouping
some themes under this dimension (see 232 to 242 and references N° 34 and N° 35 in
the revised manuscript).
7. There is only brief mention of limitations on data quality. This could be addressed
in more detail.
Our response
We expanded this more in the limitations section. We highlighted the fact that, given
the lack of appraisal of the data quality and the fact that we did not comprehensively
search for grey literature, the conclusions of this review still need to be confirmed
by good empirical studies (see line 622 to 625 in the revised manuscript).
8. References: I am curious about why DOIs were not routinely included.
Our response
We corrected the references list by including the DOIs.
9. There are several categorical statements in the manuscript which are clearly false,
or end up being contradicted later. One of these being line 237: “The GPs […] are
medical doctors with a mere undergraduate training.” Unfortunately, this is simply
not true. Most countries require some form of vocational training following an undergraduate
degree, prior to working as a general practitioner or medical officer. This could
be a rotating one or two year internship as well as an additional year of community
service. As an example of conflicting information, lines 277 – 278 “…most of the MGCs
work in CHCs, which are public entities…” contradicts line 224 which states “The MGCs
work in the private sector and claim not-for profit status.” Table 6 is also prone
to such errors (eg: FPs “do not provide first-contact care”), and should be reviewed.
A final careful read-through of the text would be important to address such discrepancies.
Our response
Thank you for the comments. We reviewed the wordings in the manuscript for more clarity
and to avoid generalised conclusions. For instance, we clarified the status of the
community health centres in Mali. They are not public entities indeed, since the State
has devolved their management to local health associations. For more clarity, we rephrased
the sentence as follows: "… most MGCs work in community health centres, which are
fully integrated into the district health map even if their management has been devolved
to local health associations..." (see line 355 to 357 in the revised manuscript).
We also clarified that, when we refer to the postgraduate training of the PCPs, we
refer to formal training that addresses the principles and specificities of primary
care and that can prepare the PCPs to work at the first-line (see line 217 to 218
in the revised manuscript). While such training exists for the family physicians and
the "médecins généralistes communautaires", the PCPs categorized as “GPs” in this
review are either the doctors for whom the papers reviewed indicate that this training
does not exist or the doctors for whom the existence of this training is not clear.
This again indicates the need for better research on this category. In Benin, for
example, apart from an internship in a rural area during the sixth year of the undergraduate
studies, there is no other requirement, once the diploma is obtained, for the doctor
to start practising. But, this is not necessarily the case in other countries.
We have carefully checked for other discrepancies throughout the document.
10. While not the focus of this current study, one wonders about the impacts of migration,
brain drain, the climate crisis and regional conflicts on the subject under review.
Even passing mention of these factors might be in order in the discussion given how
prevalent and weighty these are for the SSA context within which this review takes
place.
Our response:
Thank you for these relevant suggestions. In the revised manuscript, we discussed
how inadequate governance of the PCPs might lead to internal or external brain drain
(see lines 567 to 572 in the revised manuscript). We have also highlighted the need
to pay attention to the role the PCPs could play in addressing the emerging challenges
that Africa is currently facing, including COVID-19 and climate changes (see line
653 to 655 in the revised manuscript).
References
1. Dugas S, Van Dormael M. La construction de la médecine de famille dans les pays
en développement. W. Van Lerberghe, G. Kegels, editors. Antwerp: ITGPress; 2003. French.
http://dspace.itg.be/bitstream/handle/10390/1526/shsop22.pdf?sequence=1.
2. Desplats D, Koné Y, Razakarison C. Pour une médecine générale communautaire en
première ligne. Med Trop. 2004;64(6):539-44. French. DOI: 10.1055/s-0029-1237558.
3. Hellenberg DA, Gibbs T, Megennis S, Ogunbanjo GA. Family medicine in South Africa:
where are we now and where do we want to be? Eur J Gen Pract. 2005;11(3):127-30. DOI:
10.3109/13814780509178253.
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