Qualitative study of the meaning of personal care in general practice

Dear Editor,

As in the UK-based study (1) of Tarrant and colleagues, Guinean
patients also consider communication with health professionals as an
important care quality criterion (2). Unfortunately, in developing
countries, Bio-medicine is the dominant paradigm (3), and poor
communication is the rule in public services. Verbal violence is often
reported and patients may be the victims of maltreatment in maternity
services (4).

Why does communication weigh so little in health policies in / for
developing countries?

The biomedical model was widely disseminated during the colonial
period. In the 1950s and 1960s, health policies in Africa and Asia focused
on disease control and their single health problem approach. Fifty years
later, international aid agencies still encourage combined cost-effective
disease control interventions as the key delivery pattern for publicly
oriented services in poor countries. As a consequence, the public sector
concentrates on quantitative objectives, adopts management per objective,
and clinical decision-making is hyper-standardised at the expense of
individually tailored care.

The problem is not limited to public oriented facilities. Admittedly,
private sector accounts for an important proportion of health offer in
developing countries and is described as offering better doctor-patient
relationship and more confidential care. However, there are reasons to
suspect that patient-centred care are as absent from private care delivery
as they are from public services:

- patient centred care is barely reflected in the medical curriculum in
developing countries (3).

- private practitioners may have little interest in non-lucrative
preventive actions (5).

- maximisation of income may conflict with promoting patient autonomy when
health care financing is inadequate and practitioners are forced to depend
on health care over-consumption for survival (5).

Consequently, as in government organisations, shared decision making
about case management, an essential element of patient-centred care, is
very difficult to achieve in private-for-profit practice in developing
countries.

Greater emphasis on patient-centred care could improve doctor patient
communication in developing countries and increase the effectiveness of
care just as it can in developed countries. We urge aid agencies and
governments to consider the patient centred approach as the object of a
specific initiative encompassing in service training, coaching, and
reorganisation of health services for these regions.

Reference List

(1)Tarrant C, Windridge K, Boulton M, Baker R, Freeman G. Qualitative
study of the meaning of personal care in general practice. BMJ 2003;
326(7402):1310.

(2)Haddad S, Fournier P, Machouf N, Yatara F. What does quality mean
to lay people? Community perceptions of primary health care services in
Guinea. Social Science & Medicine 1998; 47(3):381-394.

(3)Unger JP, Van Dormael M, Criel B, Van der Vennet J, De Munck P. A
plea for an initiative to strengthen family medicine in public health care
services of developing countries. International Journal of Health Services
2002; 32(4):799-815.

(4)Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients?
Reflections from South African obstetric services. Social Science &
Medicine 1998; 47(11):1781-1795.

(5)Thaver IH, Harpham T, McPake B, Garner P. Private practitioners in
the slums of Karachi: what quality of care do they offer? Social Science
& Medicine 1998; 46(11):1441-1449.

Competing interests:  
None declared