Rethinking global primary healthcare worker education: the value of multi-directional learning

By Dr Matt Harris, Jane Beston, Dr Mamsallah Faal-Omisore, PCI and Dr Niall Winters, University of Oxford

What does it mean to ‘build capacity’ of healthcare workers globally? We know that clinical expertise must be matched with knowledge and appreciation of context – politics, policy, economy, culture.

What does it mean to ‘build capacity’ of healthcare workers globally? We know that clinical expertise must be matched with knowledge and appreciation of context – politics, policy, economy, culture. As resources are redirected to economic recovery from COVID-19, most obviously demonstrated in the recent dramatic cuts to UK development assistance, there is now an opportunity to radically rethink our approaches to learning and recalibrate current dynamics.

Primary care is widely recognised as the best way to ensure the delivery of quality healthcare to most people, most of the time, and it must be underpinned by a well-equipped health workforce. Too frequently have models of primary care been imposed by external ‘experts’, leaving many to question their role in such projects which may, at best, be as grateful participants, and at worst, as passive recipients. However for those who still doubted it, COVID-19 has, in many ways, taught us that solutions can and should come from anywhere.

There is growing discussion regarding the importance of reverse innovation, where ideas originating in so-called low resource settings are adopted by higher income countries. Its ‘sibling’, ‘reverse education’, prioritises and values a collaborative knowledge base that is globally, nationally and locally relevant. Indeed, there has been discussion about using the COVID-19 pandemic to reimagine global health teaching in high-income countries – to centre voices from the Global South and Indigenous scholars. These all advance an aspiration to move beyond outdated models described above. We believe the future of primary care must be about innovation inspired by practitioners collaborating with similar groups in other parts of the world to bring richness and sustainability to efforts borne out of multi-directional learning – a dynamic growth mindset between settings, co-creating learning, underpinned by the principles of adult learning to develop leaders.

First, we must learn together in a process of co-creation. The evidence base for health worker learning can be informed by international sources and contextualised for regional or national context and guidelines. There is no one size fits all approach here, all partners involved should work together to develop evidence-based, pragmatic, actionable guidance and learning resources for primary care delivery – that will work in different contexts and communities. This is a real opportunity for self-reflection by those involved in delivering learning for health workers. Where is your model coming from and where is the evidence underpinning this?

Second, we must learn from within using the key principles of adult learning theory. Different to pedagogy, where learners are taught and dependent on the ‘teacher’ as expert, andragogy challenges this potential power imbalance and places the subject itself as the centre of the learning experience. It presents an alternative process in which teachers become facilitators, opening up thinking and creating options. Andragogy integrates the pre-existing knowledge and skills of adult learners and promotes individual ownership and application of learning. In this model, content can be immediately applied to real-life and ‘live’ situations and the real and tangible (rather than perceived) needs of learners can be addressed. This approach doesn’t impose a model, rather it allows for collective and open learning to innovate and develop ways of working that are effective in any given context.

Third, we must learn to lead. Multi-directional learning concepts should inform a focus on leadership development in settings around the world. Having skills in leadership will enable health workers to champion the role of the primary healthcare workforce at policy level and contribute to growing a global movement of primary care leaders.

Learning from each other, learning from within, and learning to lead requires creating and facilitating global communities of practice, enabling access to peer support at scale and facilitating learning beyond a specific context or cohort. It’s essential to reflect on what other avenues exist for us to connect with globally and really develop a co-produced sense of what good quality primary care is. For example, how can we better bring learning from to the UK, where there are many strengths in the primary healthcare system and its workforce but also weaknesses e.g. doctor-centred and not sufficiently community based.

Global communities of practice require a global faculty to nurture them. One way that we can ensure multi-directional learning in practice is through a faculty which is globally co-located: recognising the value of expertise and insight in its many forms and avoiding the pitfalls of ‘groupthink’. This is also necessary if we are to hold ourselves to account to proactively foster and promote anti-racism across our organisations.

Primary health worker training and teaching of the future must have multi-directional learning embedded into its approach. Primary Care International (PCI) is one such organisation who have placed this approach at the heart of their work. This includes their new Academy, a blended learning hub for primary care practitioners, which seeks to offer a model for how this ethos can be operationalised in practice.

The message coming through in the response to the COVID-19 pandemic is that no one is safe until everyone is safe. Indeed, growing interconnectedness in an increasingly globalised world also brings home the fact that we all have something to learn from each other. Taking a multi-directional approach to learning can bring real value and innovation- we just need to prove – and scale-up – models of how best this can happen in practice.

This article is part of Primary Care International’s co-authored Op-Ed series Primary Care Perspectives, exploring resilient systems and healthy populations in the context of COVID-19 and beyond. The perspectives of the authors are not necessarily the views of any of their institutions or affiliations. 


Dr Matt Harris- Clinical Senior Lecturer in Public Health, in the Department of Primary Care and Public Health, Imperial College London, and an Honorary Consultant in Public Health Medicine in the Imperial College Healthcare NHS Trust.

Jane Beston – Head of Product Development for Primary Care International and extensive experience in the field of learning and professional development.

Dr Mamsallah Faal-Omisore – Clinical Director for Primary Care International, General Practitioner (London, Lagos) and Faculty at the Healthcare Leadership Academy, Lagos.

Dr Niall Winters – Professor of Education and Technology at the Department of Education, University of Oxford, where he is also a Fellow of Kellogg College

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